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In Page Analytics of Workshop Blog/Website, on November 15, 2014

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In Page Analytics of Workshop Blog/Website, on November 15, 2014

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http://physicalexaminationproceduralskills.blogspot.sg

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http://searame2014.org/wp-content/uploads/2014/11/SEARAME-proceedings-book-final1.pdf

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On real patients

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Disadvantages: Few log bookes are ompleted

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Demonstartion

Practice

Monitoring/supervision

Disadvantages:

Resource limitations

How to improve:

Authentic simulatiors

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Cases

Simulation lab

Advantages:

Traditional - can accommodate with large no. of students

How to improve:

To adapt

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Practising on each other

Disadvantages:

Challenging if resources are not available

Bedside teaching may be compromised

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Feedback

Practice

Disadvantage: low fidelity

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Clinical skill room (simulation)

Advantages:

Good when patients who are approachable are few

Disadvantage:

Less patients

How to improve:

Simulated cases

Rationalize to the students (why do it)

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12 tips for increasing transfer of training from faculty development programs, Medical Teacher, November 2014

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12 tips for increasing transfer of training from faculty development programs, Medical Teacher, November 2014

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http://informahealthcare.com/doi/abs/10.3109/0142159X.2014.929098

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http://physicalexaminationproceduralskills.blogspot.sg/

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Workshop Title:
Hybrid model for training physical examination and procedural skills
Workshop Synopsis:
The purpose of this workshop is to re-examine physical examination and procedural skills training - by evaluating current educational theory, and empirical best practices; and then proposing a hybrid blended training model; by exploring how the eLearning, simulation, and mastery training paradigms can add value and insights to traditional training curricula. We will use three practical scenarios as illustrations and educational practice examples - abdominal physical examination, suturing, and corneal foreign body removal.
Workshop Website/Interactive digital wall
http://padlet.com/dnrgohps/trainPEprocSK

( Workshop Program:
1345 to 1515hrs (90 minutes)
Introduction
Good morning. There will be three parts to this workshop. Part 1, an individual and table discussion followed by interactive presentation; Part 2, a presentation of one method to think about this teaching and training conundrum; and finally Part 3, an interactive Q and A, followed by reflection and summing up section.
Professor Khan sends his apologies for not being able to attend this workshop due to a late logistical problem, and Gominda will deputise on his behalf, by taking down your responses to each question, writing a summary on the Padlet wall, and playing the role of a "traditionalist" if necessary.

Review of workshop participant feedback to questions (15 minutes) Part 1:

Please reflect on the following three questions first individually, for a couple of minutes, write down your answer, and I will then nominate a volunteer from each row to come up to the podium/microphone to share a summary of your responses to the questions with the group.
posed to workshop participants live, by email beforehand, via online Survey) (Alternative arrangement if room is organised with participants seated around four tables is for a small group discussion to occur after personal reflection, and one or two nominees from each table to present their responses to the questions to the whole group. Please introduce yourself to your fellow educationalists seated at the table in the first minute or two).
A. How do you currently teach physical examination and procedure skills training?
B. What do you feel are the strengths of the current training program?
C. What do you feel are the weaknesses of your current training program? What could be improved? How might you do this?

Q and A interactive discussion.

Lets use a sporting analogy, and reflect on how this is similar to the training process for physical examination and procedural skills.

Interactive presentation and discussion, with each row volunteer, or nominee from each table, presenting their comments to the three questions. Consider the desire to play tennis. From a beginner's or novice's point of view, a good amateur player, or aspiring professional tennis player.
How would you learn to play tennis. And perform well.
One process would be to watch videos of a range of tennis players, from good amateurs, to a range of the top professionals. Paying attention to a variety of styles, and strategies. With different competition. On different surfaces. And different playing conditions.
Part 2: You would get some coaching. Go for lessons.
Your teacher or coach would explain the principles of stroke making, demonstrate the forehand or serve, get you to role play or mimic his or her action/stroke making, and start you first hitting slow balls tossed on same side of court to you, then from across the net (close first, then further), then hit to you. You make half strokes, then 3/4 stroke actions, then full stroke actions. You would hit gently first, staying in one place, then take increaing steps to hit a ball placed further from you, hit to you at greater pace. You would be asked to repeatedly practice forehands, then backhands and so one. You would eventually play with the coach, before moving on to play with a variety of opponents. While the coach constantly gives you feedback, and you reflect on your performance. Good coaches would video tape your performance, and you and your coach would watch these performances, repeatedly, and then go back to the practice court.
This process would repeat itself. You would play progressively better players, longer matches, under tougher conditions, with less rest periods.
Does this process remind you of teaching and training for physical examination and procedural skills.
You would want to view, and watch competent, proficient, and ideally master clinicians. The very best in their area. Not only how they examine patients, but how a variety of master clinicians perform procedures. Train with the very best. Learn from them. Try to model them. Get them to coach you. And keep giving you feedback. You would repeat this process. Again and again. Under more difficult conditions.
Travel to see the best.
Watch videos of the best performers.
Practice with coaching and feedback.
Videotape your own performances.
Watch yourself.
Get respected, and master clinicians to give you feedback.
The analogy between sports, in this case learning and training to be a tennis player, and physical examination and procedure skills training in health professions education should be quite clear.
A current model which several of you have shared is a live demonstration, with or without an earlier video demonstration, followed by small group student practice either in a simulation centre, or on volunteers, followed by individual instructor feedback, and then further practice and experience with selected patients, either simulated or actual patients.
What we can learn from the sporting analogy, or a training to be a chef analogy, is repeated iterative practice, using a mastery training model. Where progression to the next stage of training is dependent on demonstrating competency and proficiency of each physical examination and procedural technique. Where any deficiencies in performance are picked up, with the student or trainee coming back for remedial focused practice with feedback.
We can add exposure to a wide range of different techniques, using digital video demonstrations, to illustrate the breadth and range of physical examination and procedural skills which can be applied in a variety of clinical settings. This simulates the previous phenomenon where a motivated trainee or student had to search widely, sometimes worldwide, to find and learn from the best practitioners in a field. We can also consider the use of video reviews of clinical examination and procedural performance, with self critique and reflection, as well as instructor feedback, following a coaching paradigm. The process to scale up this process, by the use of senior students, is used by several groups, and is also used in the sporting and other skill training settings.
Interactive Q and A.
Concluding statements.
Thank you.

Original planned format of workshop below for your reference.
_______________________
Review of current approaches to training (Junaid Sarfraz Khan) 15 minute presentation
Q and A
___________
Review of how the eLearning and simulation literature and empirical evidence can help refine and improve current training and education programs (Poh-Sun Goh) 15 minute presentation
Q and A
_____________
Interactive group discussion (30 minutes)
Workshop review and closing comments (15 minutes)
_______________

Review of how the eLearning and simulation literature and empirical evidence can help refine and improve current training and education programs (Poh-Sun Goh) 15 minute presentation.
What is the role of comprehensive physical examination when cross sectional imaging is widely available?
Is the role of physical examination to screen, to comprehensively evaluate or to aid decision making (conservative, operate or discharge)?
How can procedural skills training programs take advantage of the literature from simulation and mastery training literature?
******** Presentation
********
What is the purpose/objective of current training and education programs?

***Knowledge
***Skills
***Attitudes
***Competencies
***Entrustable professional activities (EPAs)
What teaching methods do we current use to fulfil these educational objectives?

***Knowledge --> Lecture, Interactive tutorial
***Skills --> Demonstrations, practice sessions with feedback (simulation, volunteer, then clinical patients)
***Attitudes --> Case studies, role-modelling, self-reflection exercises
***Competencies
***EPAs
What do we know from the literature?

What do we know from our own experience and empirical practice?

***How do we learn?
***What do we observe on a day to day basis?
Undergraduates?
Postgraduates?
Lifelong learning?
What are our own successful learning experiences?
***How were we taught in medical school?
***How were we trained (postgraduate)?
***What are our best experiences in later professional practice?
As participants?
As faculty and program leads?
How can we refine and improve current training programs?
***Keep the best of what we do currently?
***What can we reduce, refine, or add to?
How can eLearning, and simulation augment current training programs?

http://vidcast.nus.edu.sg/camtasiarelay/Imaging_of_Respiratory_Tract_Disorders_-_20141105_151527_25.html

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Hybrid model for training physical examination and procedural skills

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Workshop Title: Hybrid model for training physical examination and procedural skills Workshop Synopsis: The purpose of this workshop is to re-examine physical examination and procedural skills training - by evaluating current educational theory, and empirical best practices; and then proposing a hybrid blended training model; by exploring how the eLearning, simulation, and mastery training paradigms can add value and insights to traditional training curricula.

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http://healthland.time.com/2012/03/14/do-e-books-impair-memory/

http://ideas.time.com/2011/10/26/why-digital-literacy-will-never-replace-the-traditional-kind/print/

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Getty Images

I received a Kindle for my birthday, and enjoying "light reading," in addition to the dense science I read for work, I immediately loaded it with mysteries by my favorite authors. But I soon found that I had difficulty recalling the names of characters from chapter to chapter. At first, I attributed the lapses to a scary reality of getting older - but then I discovered that I didn't have this problem when I read paperbacks.

When I discussed my quirky recall with friends and colleagues, I found out I wasn't the only one who suffered from "e-book moments." Online, I discovered that Google's Larry Page himself had concerns about research showing that on-screen reading is measurably slower than reading on paper.

This seems like a particularly troubling trend for academia, where digital books are slowly overtaking the heavy tomes I used to lug around. On many levels, e-books seem like better alternatives to textbooks - they can be easily updated and many formats allow readers to interact with the material more, with quizzes, video, audio and other multimedia to reinforce lessons. But some studies suggest that there may be significant advantages in printed books if your goal is to remember what you read long-term.

VIDEO: Trippy Video: Inside the World Series of Memorization

Kate Garland, a lecturer in psychology at the University of Leicester in England, is one of the few scientists who has studied this question and reviewed the data. She found that when the exact same material is presented in both media, there is no measurable difference in student performance.

However, there are some subtle distinctions that favor print, which may matter in the long run. In one study involving psychology students, the medium did seem to matter. "We bombarded poor psychology students with economics that they didn't know," she says. Two differences emerged. First, more repetition was required with computer reading to impart the same information.

Second, the book readers seemed to digest the material more fully. Garland explains that when you recall something, you either "know" it and it just "comes to you" - without necessarily consciously recalling the context in which you learned it - or you "remember" it by cuing yourself about that context and then arriving at the answer. "Knowing" is better because you can recall the important facts faster and seemingly effortlessly.

"What we found was that people on paper started to 'know' the material more quickly over the passage of time," says Garland. "It took longer and [required] more repeated testing to get into that knowing state [with the computer reading, but] eventually the people who did it on the computer caught up with the people who [were reading] on paper."

Context and landmarks may actually be important to going from "remembering" to "knowing." The more associations a particular memory can trigger, the more easily it tends to be recalled. Consequently, seemingly irrelevant factors like remembering whether you read something at the top or the bottom of page - or whether it was on the right or left hand side of a two-page spread or near a graphic - can help cement material in mind.

MORE: Why Remembering Names Is Hard - and What to Do About It

This seems irrelevant at first, but spatial context may be particularly important because evolution may have shaped the mind to easily recall location cues so we can find our way around. That's why great memorizers since antiquity have used a trick called the " method of loci " to associate facts they want to remember with places in spaces they already know, like rooms in their childhood home. They then visualize themselves wandering sequentially through the rooms, recalling the items as they go.

As neuroscientist Mark Changizi put it in a blog post:

In nature, information comes with a physical address (and often a temporal one), and one can navigate to and from the address. Those raspberry patches we found last year are over the hill and through the woods - and they are still over the hill and through the woods.

And up until the rise of the web, the mechanisms for information storage were largely spatial and could be navigated, thereby tapping into our innate navigation capabilities. Our libraries and books - the real ones, not today's electronic variety - were supremely navigable.

E-books, however, provide fewer spatial landmarks than print, especially pared-down versions like the early Kindles, which simply scroll through text and don't even show page numbers, just the percentage already read. In a sense, the page is infinite and limitless, which can be dizzying. Printed books on the other hand, give us a physical reference point, and part of our recall includes how far along in the book we are, something that's more challenging to assess on an e-book.

Jakob Nielsen, a Web "usability" expert and principal of the Nielsen Norman Group, believes e-reading does lead to a different type of recall. "I really do think we remember less" from e-books, he says. "This is not something I have formally measured, but just based on both studies we've done looking at reading behavior on tablets and books and reading from regular computers."

He says that studies show that smaller screens also make material less memorable. "The bigger the screen, the more people can remember and the smaller, the less they can remember," he says. "The most dramatic example is reading from mobile phones. [You] lose almost all context."

Searching by typing or scrolling back is also more distracting than simply turning back pages to return to an important point, he notes. "Human short-term memory is extremely volatile and weak," says Nielsen. "That's why there's a huge benefit from being able to glance [across a page or two] and see [everything] simultaneously. Even though the eye can only see one thing at a time, it moves so fast that for all practical purposes, it can see [the pages] and can interrelate the material and understand it more."

Flipping through pages is also less mentally taxing. "The more you have to expend your minimal brain power to divert it into these other tasks [like search, the less it is] available for learning."

This doesn't mean that there isn't a place for e-text books or computerized courseware, however. Neither Nielsen nor Garland is opposed to using new media for teaching. In fact, both believe that there are many situations in which they can offer real advantages. However, different media have different strengths - and it may be that physical books are best when you want to study complex ideas and concepts that you wish to integrate deeply into your memory. More studies will likely show what material is best suited for learning in a digital format, and what type of lessons best remain in traditional textbooks.

But someone - perhaps the publishing industry? - is going to have to take the initiative and fund them.
MORE: 'Digital Literacy' Will Never Replace the Traditional Kind
Maia Szalavitz is a health writer for TIME.com. Find her on Twitter at . You can also continue the discussion on TIME Healthland's Facebook page and on Twitter at @TIMEHealthland.

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Do E-Books Make It Harder to Remember What You Just Read?

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I received a Kindle for my birthday, and enjoying "light reading," in addition to the dense science I read for work, I immediately loaded it with mysteries by my favorite authors. But I soon found that I had difficulty recalling the names of characters from chapter to chapter.

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The literature on healtcare simulation based education: what does it show, David Cook (2013)

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The literature on healtcare simulation based education: what does it show, David Cook (2013)

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Meta-analysis and perspective article

http://webmm.ahrq.gov/perspective.aspx?perspectiveID=138

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Introduction to clinical skills and procedural skills training

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Introduction to clinical skills and procedural skills training

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https://www.google.com.sg/url?sa=t&rct=j&q=&esrc=s&source=web&cd=8&cad=rja&uact=8&ved=0CGoQFjAH&url=http%3A%2F%2Fwww.primarycare.severndeanery.nhs.uk%2Fassets%2FPrimary-Care%2FInfo-for-Trainees%2FDOPS-16-10-14-training-manual.docx&ei=GXhVVLjUH82nuQT6loDAAQ&usg=AFQjCNFKkoQBybrLKrELhKBQRrdnjrvkjA&bvm=bv.78677474,d.c2E

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http://www.osceskills.com/e-learning/subjects/abdominal-examination/

http://www.osceskills.com/

Compare and contrast this website for "eLearning" with the demonstration video below.

https://www.youtube.com/watch?v=ux607iZi8-k

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Foreword

This is essentially an examination of the patient's abdomen; it is also called the gastrointestinal (GI) examination. It is a complex procedure which also includes examination of other parts of the body including the hands, face and neck.

The abdominal examination aims to pick up on any gastrointestinal pathology that may be causing a patient's symptoms, for example: abdominal pain or altered bowel habit. This examination is performed on every patient that is admitted to hospital and regularly in clinics and general practice.

Like most major examination stations this follows the usual procedure of:

It is an essential skill to master and is often examined in OSCE's.

Procedure Steps

Step 01

Wash your hands, introduce yourself to the patient and clarify their identity.

Explain what you would like to do and obtain consent. A chaperone should be offered for this examination.

Step 02

The patient should initially be laid on the bed and exposed from the waist up.

Begin by making a general inspection of the patient from the end of the bed. You should be looking for:

Whether they are comfortable at rest.

Do they appear to be tachypnoeicz?

Are there any obvious medical appliances around the bed (such as patient controlled analgesia)?

Are there any medications around the bed (although this is unlikely as all medications should be in a locked cupboard)?

Each of these should be reported to the examiner.

Step 03

Move on to examine the patient's hands. You are looking for the presence of:

Ask the patient to hold their hands out in front of them looking for any signs of a tremor. Them to extend their wrists up towards the ceiling keeping the fingers extended and look for a .

Step 04

Now is a good time to assess the radial pulse. There is some argument as to whether this should be performed or not in an abdominal exam; however, it can be a good indication of sepsis or thyroid disease.

Step 07

Now move on to examine the chest.

You should in particular look for gynaecomastia in men and the presence of 5 or more spider naevi. These are both stigma of liver pathology.

Step 08

At this point ask the patient to lie as flat as possible with their arms straight down beside them and begin your inspection of the abdomen. Comment on any obvious abnormalities such as scars, masses and pulsations. Note if there is any abdominal distension.

Step 09

Unlike other examinations, auscultation for bowel sounds may be carried out before percussion and palpation due to adverse effect that these procedures may have on the sound from the bowels.

Listen with the diaphragm next to the umbilicus for up to 30 seconds. High pitched or absent sounds may indicate bowel obstruction. Absence of sounds may be also be caused by peritonitis.

Step 11

Initial examination should be superficial using one hand. Place the hand flat over each area and flex at the metacarpophalangeal joints. You should feel whether the abdomen is soft but you should always be looking at the patient's face for any signs of pain. If you feel any abnormal masses you should report these to the examiner.

Step 12

Once all 9 areas have been examined superficially, you should move on to examine deeper.

A deeper exam is performed with two hands, one on top of the other again flexing at the metacarpophalangeal MCP joints. You should still be looking at the patient's face for them flinching due to pain. Again, examine all 9 named segments of the abdomen.

Step 13

Having performed a general examination of the abdomen, you should now feel for organomegaly, particularly of the liver, spleen and kidneys.

Palpation for the liver and spleen is similar, both starting in the right iliac fossa.

For the liver, press upwards towards the right hypochondrium. You should try to time the palpation with the patient's breathing-in as this presses down on the liver. If nothing is felt you should move towards the costal margin and try again.

A distended liver feels like a light tap on the leading finger when you press down. If the liver is distended, its distance from the costal margin should be noted.

Step 14

Palpating for the spleen is as for the liver but in the direction of the left hypochondrium. The edge of the spleen which may be felt if distended is more nodular than the liver.

Another way to assess for splenomegaly is to ask the patient to lie on their right side. Support the rib cage with your left hand and again ask the patient to take deep breaths in moving your right hand up towards the left hypochondrium.

Step 15

To feel for the kidneys you should place one hand under the patient in the flank region and the other hand on top. You should then try to ballot the kidney between the two hands. In the majority of people the kidneys are not palpable, but they maybe in thin patients who have no renal pathology.

Step 16

Palpate for the bladder by starting at the umbilicus, move in steps downwards towards the pubic bone

Step 17

Next you should percuss. This can be also be used to check for organomegaly if it is suspected.

Percussion over the abdomen is usually resonant, over a distended liver it will be dull. Percussion can also be used to check for shifting dullness - a sign of ascites.

With the patient lying flat, start percussing from the midline away from you. If the percussion note changes, hold you finger in that position and ask the patient to roll towards you. Again percuss over this area and if the note has changed then it suggests presence of fluid such as in ascites.

A distended bladder will also be dull to percussion and this should be checked for.

Step 18

Palpate for the abdominal aorta to check whether it is expansile, which could be suggestive of an aneurysm. Note that the aortic pulsation can often be felt in thin patients, but shouldn't be expansile.

Step 19

At this point, you should mention to the examiner that you would like to finish the procedure with an examination of the hernial orifices, the external genitalia and also a rectal examination.

It is also appropriate to perform a urinalysis at this point including a pregnancy test in females.

Step 20

Allow the patient to dress and thank them. Wash your hands and report any findings to your examiner.

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Abdominal (GI) Examination · Gastrointestinal · OSCE Skills, by Medistudents

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This is essentially an examination of the patient's abdomen; it is also called the gastrointestinal (GI) examination. It is a complex procedure which also includes examination of other parts of the body including the hands, face and neck.

# data[].attributes.headline
Use of online clinical videos for clinical skills training for medical students: benefits and challenges (Google search "eLearning for physical examination and procedure skills training"

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Use of online clinical videos for clinical skills training for medical students: benefits and challenges (Google search "eLearning for physical examination and procedure skills training"

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http://www.biomedcentral.com/1472-6920/14/56
"The present study confirms the overall positive impact of OSCE videos on student learning of clinical skills. Having faculty integrate these learning resources into their teaching, integrating interactive tools into this e-learning environment to foster interactions, and using mobile devices for convenient access are recommended to help students make more effective use of these resources." Hye Won Jang and Kyong-Jee Kim ((2014)
http://www.ijocs.org/issues/vol8iss1.aspx
The absence of strong correlation between video popularity and the assessors’ findings suggests that users of the website are not always able to discriminate between videos of low and high educational value. However, if high quality videos are identified to students, YouTube could be a useful educational tool. Kieran Kennedy, Brian Stewart, Gloria Avalos (2014)
http://www.linkedin.com/company/suturetutorplus-e-learning-course-and-suturing-kit-from-limbs-&-things-learning-online?trk=rr_brands_carousel_logo
Course content consists of a combination of:

computer graphics and videos which clearly explain the principles

video of the techniques being demonstrated on medical models

clinical video of the procedures on a patient

Content is broken down into clearly structured modules, chapters and topics with explanatory on screen text and full narration.

Unlike other online courses, the Limbs & Things learning online material is supported by hands-on models and materials. This gives you a unique and comprehensive learning experience - enabling you to not only understand the theory but repeatedly practise the techniques and procedures.

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Physical examination and procedural skills

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Physical examination and procedural skills

# data[].attributes.body
http://books.google.com.sg/books?id=KW2rAAAAQBAJ&pg=PA202&lpg=PA202&dq=how+can+simulation+be+used+in+physical+examination+and+procedural+skills+training&source=bl&ots=Whx5X6mE07&sig=u1h0hA_XSAqw-MG3GAbbo6Nwbk8&hl=en&sa=X&ei=9m5VVOj_Ms-nuQSVjoCYAg&ved=0CFcQ6AEwCQ#v=onepage&q=how%20can%20simulation%20be%20used%20in%20physical%20examination%20and%20procedural%20skills%20training&f=false

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Providing a comprehensive and evidence-based reference guide for those who have a strong and scholarly interest in medical education, the Oxford Textbook of Medical Education contains everything the medical educator needs to know in order to deliver the knowledge, skills, and behaviour that doctors need.

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Simulation based learning - just like the real thing

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Simulation based learning - just like the real thing

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966567/
Simulation is a technique for practice and learning that can be applied to many different disciplines and trainees. It is a technique (not a technology) to replace and amplify real experiences with guided ones, often “immersive” in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion. Simulation-based learning can be the way to develop health professionals’ knowledge, skills, and attitudes, whilst protecting patients from unnecessary risks. Simulation-based medical education can be a platform which provides a valuable tool in learning to mitigate ethical tensions and resolve practical dilemmas. Simulation-based training techniques, tools, and strategies can be applied in designing structured learning experiences, as well as be used as a measurement tool linked to targeted teamwork competencies and learning objectives. It has been widely applied in fields such aviation and the military. In medicine, simulation offers good scope for training of interdisciplinary medical teams. The realistic scenarios and equipment allows for retraining and practice till one can master the procedure or skill. An increasing number of health care institutions and medical schools are now turning to simulation-based learning. Teamwork training conducted in the simulated environment may offer an additive benefit to the traditional didactic instruction, enhance performance, and possibly also help reduce errors.
Fatimah Lateef (2010)

http://psnet.ahrq.gov/primer.aspx?primerID=25
http://qualitysafety.bmj.com/content/19/Suppl_2/i34.full.pdf%20html
http://mci-forum.com/category/challenges/611-use_of_simulation_and_military_medical_training_2014.html

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Abstract

Simulation is a technique for practice and learning that can be applied to many different disciplines and trainees. It is a technique (not a technology) to replace and amplify real experiences with guided ones, often "immersive" in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion. Simulation-based learning can be the way to develop health professionals' knowledge, skills, and attitudes, whilst protecting patients from unnecessary risks. Simulation-based medical education can be a platform which provides a valuable tool in learning to mitigate ethical tensions and resolve practical dilemmas. Simulation-based training techniques, tools, and strategies can be applied in designing structured learning experiences, as well as be used as a measurement tool linked to targeted teamwork competencies and learning objectives. It has been widely applied in fields such aviation and the military. In medicine, simulation offers good scope for training of interdisciplinary medical teams. The realistic scenarios and equipment allows for retraining and practice till one can master the procedure or skill. An increasing number of health care institutions and medical schools are now turning to simulation-based learning. Teamwork training conducted in the simulated environment may offer an additive benefit to the traditional didactic instruction, enhance performance, and possibly also help reduce errors.

Keywords: Simulation, learning, virtual reality, medical education

INTRODUCTION

In medical education, there should be exposure to live patients so that medical students and doctors can acquire the necessary skills. There is also, on the other hand, an obligation to provide optimal treatment and to ensure patients' safety and well-being. These two competing needs can sometimes pose a dilemma in medical education. Also, medicine is a discipline that is a science as well as an art and repeated exposures with enhanced experience will help improve skills and confidence.[ 1]

The growing complexities of patient care require doctors to master not only knowledge and procedural skills but also the ability to effectively communicate with patients, relatives, and other health care providers and also to coordinate a variety of patient care activities. Doctors have to be good team players and their training programmes must systematically inculcate these skills. Teamwork-related competencies are relatively new considerations in the arena of health care

SIMULATION-BASED LEARNING

Simulation is a technique for practice and learning that can be applied to many different disciplines and types of trainees. It is a technique (not a technology) to replace and amplify real experiences with guided ones, often "immersive" in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion. "Immersive" here implies that participants are immersed in a task or setting as if it were the real world.[ 2, 3]

Full-body mannequin simulators originated in the field of anesthesia in the late 1960s, based on work done by Denson and Abrahamson from the University of Southern California. This model was known as 'Sim One' and was used for training in endotracheal intubation and induction of anesthesia. In the 1980s, during the time when personal computers became less expensive and more simulation software became available, independent groups began to develop simulator systems. Much of this was utilized in the areas of aviation, military training, nuclear power generation, and space flights. In the early 1990s, more comprehensive anesthesia simulation environments were produced, which included the MedSim and, later, the Medical Education Technologies Inc. (METI) Advanced Human Patient Simulator. Aviation simulation training concepts then begun to be gradually introduced into anesthesia and other areas of medicine like critical care, obstetrics, emergency medicine, and internal medicine. Current full-body simulator models incorporate computerized models that closely approximate the physiology seen in the human body.

Simulation-based learning can be the answer to developing health professionals' knowledge, skills, and attitudes, whilst protecting patients from unnecessary risks. Simulation-based medical education can be a platform for learning to mitigate ethical tensions and resolve practical dilemmas. Simulationbased training techniques, tools, and strategies can be applied in designing structured learning experiences, as well as be used as a measurement tool linked to targeted teamwork competencies and learning objectives. Simulation-based learning itself is not new. It has been applied widely in the aviation industry (also known as CRM or crew resource management), anesthesiology, as well as in the military. It helps to mitigate errors and maintain a culture of safety, especially in these industries where there is zero tolerance for any deviation from set standards.[ 1, 3]

Simulation has also begun to change much of the ways in which medicine is taught and how trainees and junior doctors acquire the relevant skills. Medical, nursing, and other health care staff also have the opportunity to develop and refine their skills, repeatedly if necessary, using simulation technology without putting patients at risk.[ 4] Simulation training centers, with their new techniques and equipment, offer unique opportunities for dynamic, complex, and unanticipated medical situations to be practiced and managed. In both aviation and health care domains, human performance is strongly influenced by the situational context, i.e., the interaction between the task, the environment, and the behavior of team members. In aviation, more than 50 years of research has shown that superior cognitive and technical skills are not enough to ensure safety: effective teamwork skill is a must. Similar observations are also now being made in the practice of medicine.[ 3- 8]

The cost of simulation training, when it was first introduced, was high, and few institutions had the vision to realize that it was a worthwhile investment for the long term. It has indeed turned out to be a very flexible and durable form of medical education and training. Much of the cost is contributed to by the manpower or technician costs as well as cost of the laboratory setup and maintenance. The computer- and information technologycontrolled equipment advances medical learning and ensures that students and doctors learn procedures and treatment protocols before performing them on actual patients. The simulated environment allows learning and re-learning as often as required to correct mistakes, allowing the trainee to perfect steps and fine-tune skills to optimize clinical outcomes.[ 5, 6] There can also be simulated examples or scenarios of rare or unusual cases that are often hard to come by in the clinical settings. The simulated situation and scenarios can give students and inexperienced junior doctors realistic exposure to such cases. It can certainly help in making books and lecture materials come alive. It helps ensure that students and trainees gain clinical experience without having to depend on chance encounters of certain cases. Many also believe that simulation-based learning enhances efficiency of the learning process in a controlled and safe environment.[ 9, 10]

In the earlier days of medicine some form of "simulation" was already being applied in the form of case scenarios and the use of case presentations. These are also being utilized to assess candidates in the objective structured clinical examination (OSCE). Life support courses such as basic and advanced cardiac life support (BCLS and ACLS, respectively), as well as basic and advanced trauma life support (BTLS and ATLS, respectively), also utilize simulation techniques and principles for learning and testing.[ 5] Simulation is a tool for learning and training as well as for assessment of performance.[ 10, 11]

The skills requirement which can be enhanced with the use of simulation include:

1. Technical and functional expertise training

2. Problem-solving and decision-making skills

3. Interpersonal and communications skills or team-based competencies

All of these share a common thread in that they require active listening and collaboration besides possession of the basic knowledge and skills. With every training programme it is best to have feedback and debriefing sessions that follow. Feedback must be linked to learning outcomes and there must be effective debriefing protocols following all simulation exercises. Studies have shown that simulation improves learning.[ 5, 6, 9, 11] Simulation is effective in developing skills in procedures that require eye-hand coordination and in those that call for ambidextrous maneuvers, such as bronchoscopy and other endoscopic procedures[ 9- 11] Simulation training helps learners prepare to deal with unanticipated medical events, thus increasing their confidence.

Multidisciplinary teams deliver a multitude of health care services today but many organizations still remain focused on individual technical responsibilities, leaving practitioners inadequately prepared to enter complex team-based settings. When health care providers of different disciplines train separately, it may be difficult to integrate their capabilities. Effective multidisciplinary teams must always have good communications and leadershipsharing behavior, which can help ensure patient safety.

Inculcation of teamwork values is an example of the nontechnical, but essential, part of training of medical professionals. Simulation has the potential to create lasting and sustainable behavior and culture change that will make health care more effective and safer. It also has the ability to fundamentally alter learners' ways of doing things and working with others. Transformational change can only come about when the learner recognizes the problems and then adopts a proactive approach to work on it and correct it.

The essence of a team is the shared goal and commitment. It represents a powerful unit of collective performance, which can be done as an individual or mutually. These must eventually translate common purpose into specific performance goals. One of the important ingredients of teams with good outcomes is the basic discipline of the team. Simulation training and practice affords the essentials for creating an effective medical team with a sense of group identity, group efficacy, and trust amongst members. There needs to be true engagement and understanding for team members to work together well. Examples of these can be seen in the incredible teamwork and excellent team dynamics that can exist during good resuscitation, certain surgery, and the more complex intensive care cases. Members who have had sufficient training and knowledge can be flexible enough to adapt to any new situation and break out of their ingrained routines and they get more proficient with time. Each member of such a health care team can carry out another team member's job, which reflects their interdependence. A learning team will have some degree of substitution, defined roles and responsibilities, flexibility, good process flow, and an awareness of common goals. Conflict resolution is another aspect of teamwork that can be practiced during simulations.

Sexton et al. used a cross-sectional survey to assess errors, stress, and teamwork in medicine and the aviation industry. Medical staff reported that error is an important issue but difficult to discuss and that it was not being handled well in their hospital.[ 12] Other problems that were mentioned included different perceptions of teamwork amongst team members and reluctance of senior staff to accept inputs from junior members.[ 12]

INTERDISCIPLINARY TEAMWORK AND SKILLS

The health care team comprises doctors from various disciplines, nurses, physiotherapists, radiologists and radiographers, pharmacists, medical students, and other personnel. The composition varies according to the objective of the teams; examples include stroke management teams, trauma teams, acute coronary syndrome intervention teams, etc. The training of each member of the team is decided by his or her own discipline. As such, there is a need to bring them together in an integrated fashion to learn how to manage a patient with complex medical problems. No one discipline is more important than the other. Everyone has a role to play. In simulated exercises involving teams, members learn how not "to step on each others' toes." They are made aware of their synergistic roles. There must also be some flexibility allowed at various junctures of decision-making and intervention. Team-work skills and interpersonal communication techniques are essential components of such training and exercise.[ 13- 16]

The simulation trainers are often senior staff who have a good grasp and helicopter view of the whole team-based approach. They must be able to objectively view the group dynamics and interaction within the teams they train and provide valuable feedback. They will assess the team's performance in real-time and may maintain checklists of activities, actions, and relevant human factors. Videotaping the role-playing is useful as it can be played back and the highlights shared with the team as part of their learning process. Trainers can points out both the negative and positive practices and behaviors to the participants.[ 16, 17]

There are also scenario writers for these simulation cases. These writers can customize the scenarios for interdisciplinary team training and role-playing in order to highlight or facilitate certain roles or team interaction. These scenarios should be realistic, practical, and comprehensive. Scenarios would usually also have event triggers, environmental distractors, and supporting events. They should be developed systematically with proficiency-based assessment in place, which can emphasize integrative team performance as well as technical performance. All practice and action should also be validated by data and evidence.[ 16]

Some common pitfalls that have been observed during team performance include:[ 17, 18]

1. The lack of understanding of roles and responsibilities of other team members, particularly across disciplines.

2. The absence of clearly defined specified roles may persist, despite generally acceptable team performance; this may not become obvious until there is a change in team members, which then reveals the role confusion.

3. Most health care systems have no or few processes or backup plans when errors occur.

4. There is an unspoken assumption by members that everyone will perform at 100% efficiency and effectiveness. However, there is no method to measure this.

SETTING UP A SIMULATION TRAINING CENTER

A simulation center would be a long-term investment in medical education. It can be used for undergraduate training (such as in the study of anatomy, physiological functions, familiarization with medical examination techniques), for residency training (e.g., in refining and mastering procedural skills and techniques or preparing for practical examinations, refresher courses, and recertification tests etc.), for continuing medical or nursing education (e.g., training in practical skills), or for competency testing prior to recruitment.[ 11] To start off, there must be a convenient location, usually somewhere on the hospital or university campus for convenience of proximity. The architecture plan and infrastructure must be decided upon in consultation with the trainers/end-users of the center. It must include adequate space for training small groups, rooms with one-way mirrors, and sufficient space for equipment setup, amongst other facilities. There must also be provision for video recording equipment. Manpower would include full-time technicians and a manager; the trainers are usually part-time medical personnel. The decision to purchase suitable mannequins and equipment must only be made after adequate demonstration and trials have been done and all parties are satisfied. It is also important to have technical support from the vendors in the long term. The different forms of medical simulation technology training that can be considered for the center would include:

1. Human patient simulators: The centerpiece is usually a fullsized patient simulator that blinks, breathes, and has heart beat, pulse, and respiratory sounds. This mannequin can be very technologically advanced. For example, it may "interact" with learners through computer-guided teaching programmes Attached monitors can display vital signs and this can provide virtual simulation of almost every major bodily function. This simulator can be used for scenarios from simple physical examination to interdisciplinary major trauma management. Some simulators can even recognize injected medications via a laser bar-code reader and then respond with appropriate vital sign changes

2. Simulated clinical environment: An intensive care unit, emergency room cubicle, or operating room is prepared with all the equipment and the crash cart. The setup is as realistic as the actual facility. Trainees can familiarize themselves with the setup and arrangements.

3. Virtual procedure stations: Various stations can be set up, depending on what the focus is. These stations will have all the relevant equipment and setup for the procedure to be carried out, e.g., bronchoscopy, colonoscopy, intubation. The simulators can present a variety of different scenarios and pathologies and the trainee can practice until he/she masters the technique(s).

4. Electronic medical records: As more health care institutions adopt electronic medical records to track and to manage patients, this can also be a station setup in the center. The system utilized will have fictitious patients with their histories, notes, and lab results. There may also be system integration, such as the link between records and the laboratory as well as the radiology results (digitalized radiographs).

Currently, adult simulation equipment and mannequins are already well established. Pediatric ones are still in the experimental stage, but there will be future developments. There are children's hospital which are already using simulation-based training for their staff.

For institutions that cannot afford to set up an entire simulation laboratory, a less expensive option could be to invest in simulation mannequins only. This could be purchased in different numbers and be used for training purposes. Institutions and their leaders must learn to accept the candidates with an open mind. The leaders must be strict with their education and training portions. It may also be useful to plan visits to established simulation centers.

SAFETY AND SIMULATION

Health care safety can be compared to other high-stakes industries such as aviation, the military, and nuclear power generation. In these industries, safety depends on the prevention of human errors and on engineered redundancy so that the systems work without failing. Morbidity and mortality can be the consequences of failures in these environments.[ 20- 23] Hospitals do include the numbers of medical errors as one of their key performance indicators. The utility of simulation in health care is certainly most interesting to consider in the context of patient safety.[ 23- 25]

One important concept in medical safety is the paradigm of how one learns. Traditionally, medicine works on the apprenticeship model. Trainees and residents begin caring for patients on their first day of internship under the supervision of more experienced staff, who provide a safety net for errors. Despite their learning about medical care before assuming responsibility of their first patient, there must indeed be a first time for the performance of high-risk procedures, resuscitation, and the implementation of critical decision-making skills in real time on real patients. Simulation provides a learning model to complement traditional learning in medicine. These scheduled simulation exposures can ensure the residents have exposure to these emergencies, even if they are only simulated scenarios. For the performance of procedures, it has been shown that the volume of experience decreases patient complication rates. Simulators do allow for the development of experience prior to performance of these procedures on patients.[ 4, 11, 23- 25]

The apprenticeship model of medical teaching has not been widely studied, but newer methods which are resourceful and intensive have been given greater scrutiny. The body of literature is gradually emerging. A general scan of the literature from 1969 to 2003 concluded that the rigor and quality of research in simulation needs improvement, although high-fidelity simulations are educationally effective and complement traditional teaching in patient care settings. The features of simulation which best facilitate learning include:[ 23, 26]

The educational benefits of simulation in medical education include the following:

To date, however, there have been no studies to show that simulation training improves patient care outcomes directly. There may be some reasons for this. Life-threatening complications are rare. Most institutions have quality improvement measures in place and selecting for the impact of simulation on patient outcomes can be difficult. However, there exist a significant body of data and evidence for the benefit of simulation training in educational outcomes. Learners who go through simulation do perform better on subsequent simulated tests and tasks. In a cohort study on medical students from five institutions, one group was exposed to 2 weeks of deliberate practice of cardiac bedside skills using the Harvey Cardiology Patient Simulator followed by 2 weeks of traditional ward work, while the other group went through 4 weeks of traditional ward training. The simulation group performed at twice as well as the ward group, with only half the training time.[ 24]

Devita et al. showed that simulated patients had better outcomes if doctors were trained to work together by reliably performing preassigned roles during a simulator exercise.[ 25]

FUTURE DIRECTIONS

Simulation appears to be here to stay. Perhaps there will be a day when we may use it as a tool in evaluating candidates for medical school admission, just as dental students are put through some manual dexterity tests. As medical simulation games are being developed, medical training may change to include a portion of time dedicated to learning through gaming. More studies and research are also needed to determine whether simulation improves patient outcomes. Designers will continue to improve the technology of virtual reality to make experiences as seamless as possible.[ 26]

CONCLUSION

Simulation-based training has opened up a new educational application in medicine. Evidence-based practices can be put into action by means of protocols and algorithms, which can then be practiced via simulation scenarios. The key to success in simulation training is integrating it into traditional education programmes. The clinical faculty must be engaged early in the process of development of a programme such as this. Champions and early adopters will see the potential in virtual reality learning and will invest time and energy in helping to create a curriculum. They can then help to engage the wider medical community. Teamwork training conducted in the simulated environment may also offer an additive benefit to the traditional didactic instruction, enhance performance, and possibly also reduce errors. The cost-effectiveness of potentially expensive simulation-based medical education and training should be examined in terms of improvement of clinical competence and its impact on patient safety. Perhaps, with the adoption of simulation as a standard of training and certification, health care systems will be viewed as more accountable and ethical by the population they serve.

Footnotes

Source of Support: Nil.

Conflict of Interest: None declared.

REFERENCES

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Simulation-based learning: Just like the real thing

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Simulation is a technique for practice and learning that can be applied to many different disciplines and trainees. It is a technique (not a technology) to replace and amplify real experiences with guided ones, often "immersive" in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion.

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Simulation based clinical skills training (Google search "how can simulation be used in physical examination and procedural skills training")

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Simulation based clinical skills training (Google search "how can simulation be used in physical examination and procedural skills training")

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http://www.bumc.bu.edu/busm-ome/cssc/

"Over the past several decades, however, simulation has been increasingly used in medical education. It has been shown to improve clinical training and promote patient safety, and is seen as a method of risk-free learning.Types of simulation used in Boston University School of Medicine’s Clinical Skills and Simulation Center (CSSC) vary from low tech role-plays to use of standardized patients (patient-actors) to high tech full body simulators. " (from/see website above)

http://www.aaos.org/news/aaosnow/sep14/clinical3.asp

"Under the newly introduced Next Accreditation System used by the Accreditation Council on Graduate Medical Education to assess program outcomes, milestones are used to verify that residents are moving through appropriate educational developmental landmarks. Many residency programs have recognized that prior methods can be inadequate to truly measure resident competency for the milestones. As a result, they have turned to simulation both to both teach skills and to assess resident competence. As a training tool, simulation can drive down costs, improve efficiency, and lower complication rates." (from/see website above)

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http://learningchestradiology.blogspot.sg/2013/11/imaging-of-respiratory-disorders-m2.html

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Conference Theme - ENHANCING CLINICAL EDUCATION IN THE HEALTH PROFESSIONS

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Conference Theme - ENHANCING CLINICAL EDUCATION IN THE HEALTH PROFESSIONS

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http://searame2014.org/

Primary Care and Community Based Medical Education
Interprofessional Education
Integration of Basic and Clinical Sciences

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(45 minutes)

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Review of current approaches to training

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Review of current approaches to training

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Junaid Sarfraz Khan

(15 minutes)

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Review of workshop participant feedback to questions (15 minutes)

(posed to workshop participants live, by email beforehand, via online Survey)

*********
A. How do you currently teach physical examination and procedure skills training?

B. What do you feel are the strengths of the current training program?

C. What do you feel are the weaknesses of your current training program?

What could be improved?

How might you do this?

*********

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Review of how the eLearning and simulation literature and empirical evidence can help refine and improve current training and education programs

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Review of how the eLearning and simulation literature and empirical evidence can help refine and improve current training and education programs

# data[].attributes.body
Goh Poh Sun

(15 minutes)

********
What is the role of comprehensive physical examination when cross sectional imaging is widely available?
Is the role of physical examination to screen, to comprehensively evaluate or to aid decision making (conservative, operate or discharge)?
How can procedural skills training programs take advantage of the literature from simulation and mastery training literature?
********

********

What is the purpose/objective of current training and education programs?

***Knowledge

***Skills

***Attitudes

***Competencies

***Entrustable professional activities (EPAs)

What teaching methods do we current use to fulfil these educational objectives?

***Knowledge --> Lecture, Interactive tutorial

***Skills --> Demonstrations, practice sessions with feedback (simulation, volunteer, then clinical patients)

***Attitudes --> Case studies, role-modelling, self-reflection exercises

***Competencies

***EPAs

What do we know from the literature?

***Learning

***Curricula

***Assessment

***eLearning and Simulation

What do we know from our own experience and empirical practice?

***How do we learn?

***What do we observe on a day to day basis?

Undergraduates?

Postgraduates?

Lifelong learning?

What are our own successful learning experiences?

***How were we taught in medical school?

***How were we trained (postgraduate)?

***What are our best experiences in later professional practice?

As participants?

As faculty and program leads?

How can we refine and improve current training programs?

***Keep the best of what we do currently?

***What can we reduce, refine, or add to?

How can eLearning, and simulation augment current training programs?

***Deliberate practice

***Mastery training

***Scaffolding

***See one, do one, teach one

***On the job training

***Feedback and coaching

***Portfolios and ePortfolios

***Self reflection

***Mentorship and modelling

Video records for self reflection and feedback/coaching

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https://www.facebook.com/media/set/?set=a.427958763919955.97086.252555291460304&type=3&l=c43396f89c

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https://twitter.com/FOSMEonline

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Tweets by FOSMEonline

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http://searame2014.org/

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What is Mastery in Diagnostic Radiology Training

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What is Mastery in Diagnostic Radiology Training

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http://learningneuroradiology.blogspot.sg/2013/02/what-is-mastery-in-diagnostic-radiology.html

http://www.slideshare.net/dnrgohps/mastery-training-in-diagnostic-radiology

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Mastery training in diagnostic radiology

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Reviewing some of the educational literature on training for mastery applied to diagnostic radiology, and demonstrating how online radiology case repositories ...

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Mastery Training and Deliberate Practice

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Mastery Training and Deliberate Practice

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http://medicaleducationelearning.blogspot.sg/2014/05/mastery-training-and-deliberate.html?view=sidebar

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Mastery training and deliberate practice: Topic - acute neuroimaging

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CaseBasedLearning@NUHS NUHS Neuroradiology Residency Curriculum Case review strategy for residents and fellows Cognitive apprenticeshi...

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Dr Goh Poh Sun. MBBS(Melb), FRCR(UK), FAMS(Singapore), MHPE(Maastricht), FAMEE. Associate Professor and Senior Consultant, Department of Diagnostic Radiology, National University Hospital, Singapore. Over 25 years of experience in clinical radiology and over 20 years teaching. Special interest in Neuroradiology, Chest and Abdominal Radiology. Over 15 years of experience in technology enhanced learning.

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Demonstration of basic good suture technique and habits. This is an instructional video to teach emergency medical care of basic suture technique when performing suturing of lacerations.

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Removing a metal foreign body from the cornea   RootAtlas.wmv

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Ophthamology Videos Uploaded by Allteb Medical Team www.alltebfamily.com نسألكم الدعـــاء

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Dr Goh Poh Sun. MBBS(Melb), FRCR(UK), FAMS(Singapore), MHPE(Maastricht), FAMEE. Associate Professor and Senior Consultant, Department of Diagnostic Radiology, National University Hospital, Singapore. Over 25 years of experience in clinical radiology and over 20 years teaching. Special interest in Neuroradiology, Chest and Abdominal Radiology. Over 15 years of experience in technology enhanced learning.

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(e)Learning

http://mededworld.org/reflections/reflection-items/September-2013/(e)Learning.aspx (reflection on eLearning)

http://www.slideshare.net/dnrgohps/for-med-edworldpublishpohsungoh

(use of case pairs can potentially improve the efficiency and effectiveness of radiology training)

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Workshop Synopsis:The purpose of this workshop is to re-examine physical examination and procedural skills training - by evaluating current educational theory, and empirical best practices; and then proposing a hybrid blended training model; by exploring how the eLearning, simulation, and mastery training paradigms and literature can add value and insights to traditional training curricula. We will use three practical scenarios as illustrations and educational practice examples - abdominal physical examination, suturing, and corneal foreign body removal. An introduction to the workshop, background reading, and additional resources are available on the workshop blog/website below. http://medicaleducationelearning.blogspot.sg/2014/07/searame-2014-november-12-to-15th-2014.html?view=sidebar