Simulation in Healthcare

Transfer of Clinical Reasoning Trained With a Serious Game to Comparable Clinical Problems: A Prospective Randomized Study Introduction Serious Games can be used effectively for clinical reasoning training in medical education. Case specificity of learning outcome elicited by Serious Games has not been studied in detail. This study investigated whether learning outcome elicited by repeated exposure to virtual patient cases is transferable to other cases addressing similar problems. Methods In this monocentric, prospective, randomized trial, 69 fifth-year medical students participated in ten 90-minute sessions of using a computer-based emergency ward simulation game. Students were randomized to 3 groups (A, B, AB) and subsequently exposed to up to 46 different virtual patients. Group A was presented with 2 specific cases that were not shown in group B and vice versa. Group AB was exposed to all 4 specific cases. After 6 weeks of using the game as a learning resource, students were presented with 4 cases addressing similar problems. For each case, an aggregate score reflecting clinical reasoning was calculated, and performance was compared across groups. Results In the final session, there were no significant between-group differences regarding the sum score reflecting aggregated performance in all 4 cases (A: 66.5 ± 7.2% vs. B: 61.9 ± 12.4% vs. AB: 64.8 ± 11.1%, P = 0.399). An item-by-item analysis revealed that there were no between-group differences regarding correct therapeutic interventions. Conclusions Previous exposure had limited impact on subsequent performance in similar cases. This study suggests that case specificity of learning outcome elicited by the serious game is low and that acquired higher-order cognitive functions may transfer to similar virtual patients. Reprints: Tobias Raupach, MD, MME, Georg-August-Universität Göttingen, Universitätsmedizin Göttingen, Göttingen, Germany (e-mail: tobias.raupach@med.uni-goettingen.de). The authors declare no conflict of interest. A.M. analyzed the data and wrote the article. S.A. helped design the study and contributed to the manuscript. T.R. conceived of the study, developed its design, provided advice on data presentation, and contributed to the manuscript. N.S. conceived of the study, developed its design, supervised the study, developed EMERGE cases, and contributed to the manuscript. All authors contributed to the critical revision of the article and approved the final manuscript for submission. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.simulationinhealthcare.com). © 2020 Society for Simulation in Healthcare

Augmented Reality Microsurgery: A Tool for Training Micromanipulations in Ophthalmic Surgery Using Augmented Reality Introduction Current methods of training microsurgical interventions have various limitations, including limited transferability to the human model, economic demands, and ethical concerns. In this article, we show how surgery simulations can overcome these issues and how, combined with the application of an intelligent tutoring system (ITS), they can be used to train tasks in ophthalmic surgery more efficiently. Methods We investigated physician trainee efficiency of learning microsurgical skills using our purpose-built microsurgery simulator that tracks a micromanipulator and displays a three-dimensional representation of the interior of a human eye in an augmented reality (AR) headset. The expertise of ophthalmic surgeons helped define five subtasks corresponding to the steps of internal limiting membrane peeling. Using our AR surgery simulation, 50 participants underwent two training sessions, one using the ITS that dynamically adapts the task sequence to the participant's progress and one using a fixed task sequence. Results We found significant improvement in micromanipulation performance in the first training session with both the ITS and classic training. In the second session, however, only the participants training with the ITS had further improvements in performance. Conclusions Results of this study demonstrate the usability of AR simulation in training micromanipulation skills and support the claim that simulators can be used in ophthalmic surgery training. This study also extends the existing literature by demonstrating an application of ITS for surgical training. The potential of this method is further analyzed in ongoing studies and discussions with experts in ophthalmic surgery. Reprints: Sandro Ropelato, MSc, ETH Zürich, SEC C 3 Scheuchzerstrasse 7, 8092 Zürich, Switzerland (e-mail: sandro.ropelato@gmail.com). The authors declare no conflict of interest. © 2020 Society for Simulation in Healthcare

The Effect of Simulator-Integrated Tutoring for Guidance in Virtual Reality Simulation Training Introduction Simulation-integrated tutoring in virtual reality (VR) simulation training by green lighting is a common learning support in simulation-based temporal bone surgical training. However, tutoring overreliance can negatively affect learning. We therefore wanted to investigate the effects of simulator-integrated tutoring on performance and learning. Methods A prospective, educational cohort study of a learning intervention (simulator-integrated tutoring) during repeated and distributed VR simulation training for directed, self-regulated learning of the mastoidectomy procedure. Two cohorts of novices (medical students) were recruited: 16 participants were trained using the intervention program (intermittent simulator-integrated tutoring) and 14 participants constituted a nontutored reference cohort. Outcomes were final-product performance assessed by 2 blinded raters and simulator-recorded metrics. Results Simulator-integrated tutoring had a large and positive effect on the final-product performance while turned on (mean difference = 3.8 points, P < 0.0001). However, this did not translate to a better final-product performance in subsequent nontutored procedures. The tutored cohort had a better metrics-based score, reflecting higher efficiency of drilling (mean difference = 3.6%, P = 0.001). For the individual metrics, simulator-integrated tutoring had mixed effects both during procedures and on the tutored cohort in general (learning effect). Conclusions Simulator-integrated tutoring by green lighting did not induce a better final-product performance but increased efficiency. The mixed effects on learning could be caused by tutoring overreliance, resulting from a lack of cognitive engagement when the tutor function is on. Further learning strategies such as feedback should be explored to support novice learning and cognitive engagement. Reprints: Steven Andersen, MD, PhD, Department of Otorhinolaryngology—Head & Neck Surgery, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark (e-mail: stevenarild@gmail.com). The authors declare no conflict of interest. The Visible Ear Simulator is an academic freeware VR simulator developed by the Alexandra Institute with lead programmer Peter Trier Mikkelsen in collaboration with Professor of Otology at Rigshospitalet, Dr. Mads Sølvsten Sørensen. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.simulationinhealthcare.com). © 2020 Society for Simulation in Healthcare

Lack of Diversity in Simulation Technology: An Educational Limitation? Summary Statement Despite increased attention on diversity in medicine and healthcare, heterogeneity in simulation technology has been slow to follow suit. In a nonsystematic review of simulation technology available in 2018 with respect to skin tone, age and sex, we found limited diversity in these offerings, suggesting limitations to educators' abilities to represent the full array of patients, conditions, and scenarios encountered in medicine and training. We highlight these limitations and propose basic strategies by which educators can increase awareness of and incorporate diversity into the simulation arena. Reprints: Rosemarie L. Conigliaro, MD, Section Chief, General Internal Medicine, Westchester Medical Center, Professor of Clinical Medicine, New York Medical College, 100 Woods Rd, Taylor Pavilion, Suite D342, Valhalla, NY 10595 (e-mail: rosemarie.conigliaro@wmchealth.org). The authors declare no conflict of interest. The original preparation of this manuscript took place while all authors were affiliated with the University of Kentucky College of Medicine. © 2020 Society for Simulation in Healthcare

Comparison of Resident Self-evaluation to Standardized Patient Evaluators in a Multi-institutional Objective Structured Clinical Examination: Objectively Measuring Residents' Communication and Counseling Skills Background For the past 30 years, there has been a growing emphasis on communication and self-evaluation skills training in graduate medical education. This is reflected in the Next Accreditation System. The Objective Structured Clinical Examination (OSCE) is widely used in graduate medical education for assessing dimensions of interpersonal communication and counseling skills. The OSCEs may be developed to target challenging clinical scenarios difficult to capture in clinical practice and can be used as a medium for resident self-evaluation. Objectives The aims of the study were to evaluate residents' interpersonal, communication, and counseling skills using Kalamazoo Essential Elements Communication Checklist in 4 clinically challenging scenarios and to compare standardized patient (SP) evaluations to residents' self-evaluation by category of medical school. Methods South East Michigan Center for Medical Education is a consortium of teaching hospitals. Member residents participate in 4 OSCEs as part of their postgraduate 1 curriculum. The OSCEs were developed to evaluate clinically relevant but difficult to capture scenarios including: (a) error disclosure/counseling an angry patient; (b) delivering bad news/end of life; (c) domestic violence; and (d) counseling a patient with colon cancer requesting alternative treatments. At the conclusion of each OSCE, SPs evaluated and residents self-evaluated their performance. Once evaluations were completed, SPs provided residents with feedback. Results Six member institutions and 344 residents participated during the 2014, 2015, and 2016 academic years. There were more international medical graduates (59%) than graduates of Liaison Committee for Medical Education–accredited medical schools. There were more males (62.2%) than females. Standardized patients rated residents higher than residents rated themselves in 2014 (<0.001), but not in 2015 or 2016. When combining all years and all residents, there was no correlation of SP and resident scores. Standardized patients rated female residents higher than female residents rated themselves (P < 0.0001). Male residents scored themselves similarly to the SPs, but male residents rated themselves higher than female residents rated themselves (P < 0.001). Standardized patient scores for male and female residents were not significantly different. Conclusions Targeted OSCEs provide an objective format to evaluate residents in challenging clinical scenarios. Resident self-evaluations did not correlate with SPs. In addition, female residents rated themselves lower than male residents and lower than SPs. There is need to develop interventions and curricula to improve resident's self-evaluation skills and in particular address lower self-evaluation by female trainees. Reprints: Benjamin J. Diaczok, MD, FACP, 44405 Woodward Ave, Pontiac, MI 48341 (e-mail: Benjamin.diaczok@stjoeshealth.org). The authors declare no conflict of interest. © 2020 Society for Simulation in Healthcare

Design Thinking–Informed Simulation: An Innovative Framework to Test, Evaluate, and Modify New Clinical Infrastructure Introduction Designing new healthcare facilities is complex and transitions to new clinical environments carry high risks, as unanticipated problems may arise resulting in inefficient care and patient harm. Design thinking, a human-centered design method, represents a unique framework to support the planning, testing, and evaluation of new clinical spaces throughout all phases of construction. Healthcare simulation has been used to test new clinical spaces, yet most report using simulation only in the late design stages. Moreover, healthcare design models have potentially underused human factors approaches calling for human-centered design. We applied a multimodal simulation-based approach underpinned by the principles of design thinking throughout the planning and construction stages of a newly renovated academic emergency department. Methods A multidisciplinary team developed and integrated 3 simulation strategies (table-top, mock-up, and in situ simulation) into the 5-step process of design thinking. Through end-user engagement, we identified potential challenges, prototyped solutions through table-top and mock-up simulations, and iteratively tested these solutions through in situ simulation within the actual clinical space. Results The team used end-user engagement and feedback to brainstorm and implement effective solutions to problems encountered before opening the new emergency department. The iterative steps and targeted use of simulation resulted in redesigning departmental processes and actual clinical space while mitigating anticipated safety threats and departmental deficiencies. Conclusions Design thinking coupled with multimodal simulation across all phases of construction enhanced the design and testing of new clinical infrastructure. Applying this approach early, thoroughly, and efficiently will help healthcare organizations plan changes to clinical spaces. Reprints: Andrew Petrosoniak, MD, Department of Emergency Medicine, St. Michael's Hospital, 30 Bond St, Toronto, Canada, M5B 1W8 (e-mail: petro82@gmail.com). Supported by Operational Readiness Department, St. Michael's Hospital. A.P. and C.H. received a nominal stipend from the funding entity to support their time in completing this work. The other authors declare no conflict of interest. This initiative was formally reviewed by institutional authorities at St. Michael's Hospital and deemed not to require full research ethics board approval. © 2020 Society for Simulation in Healthcare

The Physical-Virtual Patient Simulator: A Physical Human Form With Virtual Appearance and Behavior Introduction We introduce a new type of patient simulator referred to as the Physical-Virtual Patient Simulator (PVPS). The PVPS combines the tangible characteristics of a human-shaped physical form with the flexibility and richness of a virtual patient. The PVPS can exhibit a range of multisensory cues, including visual cues (eg, capillary refill, facial expressions, appearance changes), auditory cues (eg, verbal responses, heart sounds), and tactile cues (eg, localized temperature, pulse). Methods We describe the implementation of the technology, technical testing with healthcare experts, and an institutional review board–approved pilot experiment involving 22 nurse practitioner students interacting with a simulated child in 2 scenarios: sepsis and child abuse. The nurse practitioners were asked qualitative questions about ease of use and the cues they noticed. Results Participants found it easy to interact with the PVPS and had mixed but encouraging responses regarding realism. In the sepsis scenario, participants reported the following cues leading to their diagnoses: temperature, voice, mottled skin, attitude and facial expressions, breathing and cough, vitals and oxygen saturation, and appearance of the mouth and tongue. For the child abuse scenario, they reported the skin appearance on the arms and abdomen, perceived attitude, facial expressions, and inconsistent stories. Conclusions We are encouraged by the initial results and user feedback regarding the perceived realism of visual (eg, mottling), audio (eg, breathing sounds), and tactile (eg, temperature) cues displayed by the PVPS, and ease of interaction with the simulator. Reprints: Salam Daher, PhD, New Jersey Institute of Technology, Ying Wu College of Computing, GITC 3420A University Heights, Newark, NJ 07102-1982 (e-mail: salam.daher@njit.edu). The authors declare no conflict of interest. The work should be attributed to University of Central Florida, Institute for Simulation & Training, College of Nursing, and College of Medicine. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.simulationinhealthcare.com). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2020 Society for Simulation in Healthcare