Last month Tuckamore Monthly took us to Africa, where Adam and his research team worked with Malawi colleagues in order to deliver simulation-augmented health professions education. Some of the challenges they encountered resemble those of our distributed province: like educators in Malawi, those in rural and remote areas of NL need proper training to deliver good simulation teaching. However, they may be lone clinical providers serving a large population, and are therefore hard pressed to leave their communities and attend a course.

This month our blog goes to sea. I recently worked as a ship’s doctor in remote parts of Atlantic Canada, and along the way I thought about rural and remote health professional education. Here’s the story.

Last summer aboard MV Akademik Ioffe, I accompanied 102 passengers to beautiful remote places like Sable Island (Nova Scotia) and François (Newfoundland). I was the Expedition Physician, but I was also an observer. Places like Sable Island and François pose questions: how do we deliver health care in remote areas, and how do we teach students to practice in them?

In academic centres, we teach our students about sophisticated technology to diagnose and treat their patients. In fact we often use sophisticated technology like computerized human mannequins, to teach them how to use sophisticated technology! However neither option is applicable in rural and remote areas. If somebody is injured in François where there is no road, for instance, caring for them is a far different proposition than in an academic emergency centre. Clinicians in remote areas must be prepared to make critical decisions and perform critical procedures without access to technology. They must rely solely upon their clinical judgment. How can we best teach this?

And what about practitioners in even more isolated locations like ships and oil installations, or those who work in the air, transporting ill patients? They too must rely on clinical judgment and be prepared to perform critical procedures. But they also have to consider the logistics of evacuation, particularly in harsh environments where distance, sea conditions and weather are serious considerations. There may be times when these factors preclude definitive care for hours or days.

Since it is impractical and even potentially unsafe for learners to experience these extreme environments firsthand, we can use simulation as a vehicle to provide this kind of training. Low-tech simulation may be especially useful for teaching low-frequency high-stakes events (like a surgical airway) that one may encounter only occasionally in remote places. Perhaps we should transport this teaching to learners in remote areas since they cannot easily travel to academic centres for courses. It is logical to use locally available material for making simple task trainers that can be left in place, and it seems ideal to use mobile simulation or tele-simulation to augment face-to-face instruction.

Ships’ logs reveal a variety of illnesses and injuries at sea. On this voyage, I had some suturing to do, and I evacuated one passenger with a potentially serious condition. A fit but elderly gentleman, he had flown many hours to join the expedition. While aboard the ship, he suddenly became breathless. When consulting in his cabin, I noticed he could not comfortably walk from his bed to his bathroom. It was too risky for him to continue sailing with us. The remote regions we would visit have few emergency resources, so I transported him to a nearby emergency department when I had the chance. In this case, context was everything.  I had to consider the likelihood of a pulmonary embolus or a heart attack and weigh those odds against travelling further and further from definitive care. To complicate matters, I had to consult with the ship’s Captain to check the weather and our planned itinerary. Finally, since the rest of us continued our voyage, I had to communicate between the patient, his family, the shipping operators, and the emergency physician who treated him ashore, with a cell service that was available only when we approached land.

I had no available diagnostic tests to help me with this case, but I did have years of rural and remote clinical experience on my side, as well as current training in performing critical procedures. (Well, a bit. It’s been a long time since I did a surgical airway, even though I usually work in a tertiary care emergency department.) The situation reminded me that we must teach our students to make purely clinical decisions, and we must also ensure that both learners and practitioners can confidently and competently perform occasional critical procedures.

Simulation is one way to go about it, and it poses many research questions: what kinds of teaching do rural and remote practitioners feel they need? Is tele-simulation feasible in NL? How often do we need to provide critical skills re-training? How can we teach students to rely on clinical judgment in a society that so values technology?

I am back on shore now. But most days at work in the academic emergency department, I take calls from rural and remote physicians with fewer resources than mine. I hope I can serve them usefully, and I look forward to hearing their thoughts on education!

Hope to see you at our upcoming Rural and Remote Emergency Medicine Conference! http://www.med.mun.ca/Emergency-Medicine/Upcoming-Courses-and-Updates.aspx

-----------------------------

Read the entire article at:

http://www.cureus.com/articles/5146-emergency-medicine-in-remote-regions

Simulation played a key role in the recent launch of the “Building a Healthy Tomorrow”^TM fundraising campaign for Memorial University’s Faculty of Medicine.

Learning through simulation has an impact on medical education by improving the skills and confidence of learners in a safe environment. The hands-on experience enabled and obtained by using simulation allows for unique opportunities outside the classroom setting and provides a safer transition into clinical rotations. Aside from medical students, many other health care professionals also benefit from simulation by acquiring new skills and reinforcing what they already know. The “Building a Healthy Tomorrow” campaign presents the opportunity to provide support in acquiring costly medical simulation technologies to ensure that Memorial University’s Faculty of Medicine continues to produce world-class physicians.

During the recent launch of the fundraising campaign, we provided a sample of what simulation, and related educational technologies can offer to learners and seasoned health care professionals.  In the spirit of simulation, our displays were interactive, hands-on experiences with live standardized patients (trained actors portraying patient encounters), tele-simulation and ultrasound guided approaches, and pediatric computerized mannequins that respond in a human-like fashion to a number of treatments.

Here is what the experience looked like for those running the simulation stations:

First, we asked Jacqueline Turner, a Standardized Patient Educator at the Clinical Learning and Simulation Centre (CLSC) to tell us what it means to her to be able to participate in simulation-based education – both in general as well as during the campaign.

Jacqueline:

Pictured John O’dea(left) Kerry lynn Willams(center) and Jackueline Turner(right).

“This ability to share feedback from the patient’s perspective is paramount in the development of student learning”

“As a former Standardized Patient (SP) I had the opportunity to experience many medical student/resident encounters.  I was trained to realistically portray the history, physical, and emotional findings of patients.  Through these encounters, I was able to witness the important role that simulation plays in the teaching of all medical students. 

From the early days of medical school, students are taught about patient centered care and the importance of listening to the patient and their story.  They are taught how to ask some of the most difficult questions, how to demonstrate active listening and how to express empathy and understanding.  While the students understand that the SP’s are portraying a role and that the story is not real, it is amazing to see how the students become so engaged and “wrapped” up in the scenario and there are moments when they truly feel the encounter is real. I have witnessed students crying during many of these encounters after hearing a patient’s story.

Furthermore, while SPs are trained to portray various roles to enhance student encounters in a safe environment, they are also trained to provide effective feedback to the learner. This ability to share feedback from the patient’s perspective is paramount in the development of student learning.  When a patient goes to see their own doctor, how often does the doctor ask the patient for feedback on their experience as their patient? When the SP shares their thoughts to the learner from the patient’s perspective, identifying to the student what they did well and what needs improvement, the students remember the feedback and it does have a valuable impact on their learning. 

As a Standardized Patient Educator, I have a more direct link to the medical students and one of the best parts of the job is hearing the feedback from the students about how much they enjoy their SP encounters and how comforting it is to have the opportunity to practice both their communication and clinical skills on SP’s in such a safe environment. 

Several years ago, I was approached by a former student who was going through her clerkship and she shared with me that she often relies on her memorable experiences of working with faculty facilitators and SP’s to help her in her dealings with real patients on the floor.  She commented that many of her peers felt that their experience of working hands-on with SPs was the highlight of their medical school training.  As an Educator working with the CLSC, I could not wish for better feedback”.

Evidently, there are numerous benefits involved with using SPs to train new students. The unique features of SP encounters and relevant feedback help to enhance and maintain the high quality of health care that is currently being delivered.  

To increase the perception of realism, we often re-create clinical environments, such as a doctor’s office or emergency room, in order to immerse both the learners and the SP in the experience.  In addition, we often combine SP’s with inanimate simulators (also known as a fake body part), enabling the learners to attempt invasive procedures, such as suturing (see photo) without harming the SP.  This is known as hybrid simulation and allows us to address many learning objectives, such as showing compassion, taking history and performing a psychomotor skill, all at once. 

Another interactive station offered to the participants during the recent campaign launch  was the chance to insert needles into simulated patient’s necks!  This station was led by Dr. Andrew Smith, one of the leading innovators within the Faculty of Medicine.

Dr. Smith:

Pictured is Dr. Smith demonstrating an ultrasound assisted intravenous procedure

“…..skills training using simulation and ultrasound is improving patient safety one line at a time”.

“The philosophy of “see one, do one, teach one” is still the most common means by which most medical students and residents learn to perform procedures such as placement of central venous catheters, even though serious concerns have been raised regarding this approach. Traditionally, these specialized catheters have been placed blindly. There is clear evidence that the use of ultrasound decreases number of attempts, increases success rates and decreases complication rates when used to guide central line placement. Incorporating simulation into training programs is another mechanism to improve patient safety by developing resident comfort and skill prior to placing lines in clinical practice. The benefits to health authorities are also quite substantial. A formal training program provides a mechanism to train residents in the evidence-based infection control practices along with other quality initiatives.

It is estimated that catheter-related blood stream infections (CR-BSI) result in system costs of $7,000 - $18,000 while increasing patient length of stay in hospital. Formal training along with other infection control practices has been shown to decrease the rate of CR-BSI. Skills training using simulation and ultrasound is improving patient safety one line at a time”.

As a potential patient, hearing Dr. Smith talk about having to insert sharp objects into my neck or arm blindly truly emphasizes the benefits of being able to use ultrasound guided approaches.  This is no longer really an option but more so a standard of practice and we should all exercise the right to request a health care provider who is well trained in these novel approaches.

If simulation is one of the pathways to training competent heath care professionals, we should spare no efforts in making sure we have all the necessary resources and infrastructure to achieve our training goals.

Finally, many students and volunteers also took part in our simulation stations (Kerry-Lynn Williams, Cody Dunne, Emily Moores, Ben Ryan, Kristopher Hoover, Megan Pollard, Tate Skinner. We have asked Kerry-Lynn Williams, a medical student, what simulation offers to her development:

Kerry-Lynn:

“For most of us medical students, when starting out in medical school, it is the first time we are on the other side of a clinical encounter. Along with all the new information comes a plethora of new skills to learn, and often the learning is done on each other or on patients. Thankfully, here at Memorial University, simulation helps bridge that gap. 

I am a medical student about to start clerkship, and I have been involved with the Tuckamore Simulation Research Collaborative since my first year. Simulation has been, and will continue to be integrated in all aspects of our curriculum - communicating with patients, practicing physical exams, mock codes and trauma codes. 

Simulation provides a valuable opportunity to practice and learn in a safe environment with no risk to patients. It helps us build confidence in our new skills and knowledge, and provides us with a means to practice these skills. This allows us, when transitioning back to the clinical encounter, to focus on patient-centered care, not worrying if our technical skills are up to par, because through simulation and practice, we know they are”.

Kerry-Lynn’s words echo the words of those involved in running simulations (Jacqueline Turner) and of those involved in designing simulations (Dr. Smith).

All in all, simulation, as an educational tool is here to stay.  It is no longer an option or luxury, it is a necessary part of the training, and lifelong maintenance of skills, knowledge and attitudes of all involved in the health care sector.  Increasingly, it is also becoming part of quality improvement and patient safety initiatives. 

In saying that, it’s important to note that simulation is an expensive educational tool. Therefore, we need to ensure that as academics, we exercise every effort to use this tool appropriately.  We need to be sure we “use the right tool for the right job”.  For example, when we teach students how to insert needles, we use low cost simulators that are built to withstand many pokes and pricks.  When we teach communication skills, we employ our Standardized Patients.  When we teach elements of health care team behavior, we use highly sophisticated mannequins. 

But, despite the best efforts, equipment still breaks. It has an “expiry date” and needs to be replaced sooner or later.  As an academic director of the Clinical Learning and Simulation Centre here at the Memorial University, I am extremely happy that the importance of simulation in the educational process, as well as some of the barriers to simulation, have been recognized and are currently an area of focus for the “Building A Healthy Tomorrow”^TM fundraising campaign for Memorial University’s Faculty of Medicine.

Simulation Research Papers September - October 2016

Fam Med. 2016 Oct;48(9):696-702.

Effectiveness of Vaginal Delivery Simulation in Novice Trainees.

The “Empty Chairs” Approach to Learning: Coast-to-Coast Canadians Run a Simulation-Based Train the Trainer Program in Mzuzu, Malawi.

By Adam Dubrowski

 

Introduction

Together, with a group of my Canadian colleagues from Calgary, Alberta (some via Doha) and London, Ontario I was privileged to represent MUN’s Faculty of Medicine during the first Train the Trainer in Simulation-Based Learning (TTT-SBL) program in Mzuzu Central Hospital and Mzuzu University in Malawi.  Our team, led by Elaine Sigalet (Doha) and consisting of Ian Wishart (Calgary) and Faizal Haji (London), was invited to Malawi by Norman Lufesi, to conduct a 2-day TTT-SBL course for facilitators who teach an Emergency Triaging, Assessment of Trauma (ETAT) course.

The TTT-SIM facilitator team (from left to right): Adam Dubrowski, Elaine Sigalet, Norman Lufesi, Ian Wishart, and Faizal Haji.

Why?

This course was developed in response to an evolving partnership between the International Pediatric Simulation Society (IPSS), the World Federation of Pediatric Intensive Care Societies (WFPICCS), and the Ministry of Health. The long-term objective of this partnership is to decrease pediatric morbidity and mortality through the introduction of context specific faculty development programs focused on pedagogy and administration of simulation programs. It is anticipated that such programs will lead to the improvement of on-going health care educational efforts and the development of effective future programs, subsequently improving health service delivery for patients in Malawi. 

What?

This was our third visit to Malawi.  The first, in 2012, was primarily an environmental scan for us to understand the health care system as a whole and to listen to the relevant stakeholders about their needs for simulation.  Together with the Malawians, we identified that their on-going ETAT course would provide the right context for implementing simulation-based learning (SBL).  The second visit in 2014, consisted of observations of ETAT courses and mapping the TTT-SBL course.  Our most recent visit’s purpose was to implement the TTT-SBL course and to observe how the newly trained facilitators performed.

Norman Lufesi, who works for the Malawi Ministry of Health and is responsible for delivery of the ETAT courses in Malawi, had a vision for revising the current format of the ETAT to include more simulation.  Although elements of simulation are already used during the ETAT, he articulated that there are a number of shortcomings.  First, the local ETAT facilitators are not trained in how to use simulation effectively.  Secondly, the simulation that is used focuses on the development of technical skills by an individual health care professional. Finally, the course now is mainly 4.5 day long filled with didactic lectures.  Norman strongly believes that ETAT should also focus on the development of team-based learning, specifically elements of leadership, team communication, and resource management.  In his opinion, improving the teaching skills of the facilitators, and adding team training as part of the ETAT course offerings will make the course more effective and shorter (aiming at 2.5 days).  He adds that at this moment ETAT is a multi-professional course, where nurses, doctors, and clinical officers work in collaboration with each other.  By including team-based training, Norman hopes that the course will become an inter-professional course where all these health professions will learn with and about each other.  Furthermore, in his vision Norman hopes that this shift towards inter-professional education will cascade into inter-professional practice, ultimately leading to improved clinical outcomes.

Over the past 2 years, our group focused on the development of a 2-day TTT-SBL course.  The scope of this course includes providing the fundamental knowledge and skills necessary to prepare learners for SBL, for designing and running simulations, and for providing proper debriefing and feedback.  During the course the learners were provided with ample opportunities to actively implement the newly gained skills and knowledge.  The inaugural TTT-SBL course, conducted in September 2016, was strategically timed just prior to an ETAT course, where the newly trained facilitators were able to test their simulation teaching skills with 30 ETAT learners.  In the spirit of experiential learning and deliberate practice, the Canadian team hung out until the end of the course to provide these new ETAT facilitators with feedback.    

The TTT-SIM facilitators, ETAT facilitators, and the cohort of the Mzuzu ETAT students.

But our work is not done yet!  Together with Norman, the Canadian team has committed to a long-term mentor-ship plan that includes four initiatives.  First, the Canadian mentor team has re-written one of the modules of the current ETAT course to minimize the amount of didactic lectures, and when appropriate, to provide more simulation experiences, especially in the areas of critical thinking, leadership and team work.  Next, as a follow-up exercise, the newly trained ETAT facilitators have been tasked with re-writing the other modules of the ETAT course.  Third, the facilitators were asked to produce a TTT-SBL manual and supporting materials that can be used as a local resource for future TTT-SBL courses.  Finally, the facilitators were asked to establish a group of dedicated individuals to formulate a process for organizing TTT-SBL courses in other parts of Malawi and conduct a review of the existing materials.

Two way street

Working on and delivering the TTT-SBL made me realize the parallels between Malawi and rural and remote Newfoundland.  Our problems are very similar.  Rural and remote areas do not have access to high fidelity, high technology simulation.  Even with low tech substitutes, the health care professionals may lack the educational skills to make it most effective, and finally these health care professionals are often the only ones available to the local patient population and taking them away from their patients can be hard.  Is there a role for a version of this 2-day TTT-SBL course in rural an d remote Newfoundland? 

I left Malawi with mixed feelings of being home sick and longing for more - the excitement and energy during both the TTT-SBL and the ETAT courses were very stimulating and rewarding. But, I know this will not be my last trip to Malawi.

Acknowledgments: I would like to thank the Tuckamore Simulation Research Collaborative, and the Dean’s office for supporting this work. I would also like to thank the other members of our team for making this happen!