Education Columns

David Klee, MD; Munson Family Medicine Residency, Traverse City, Michigan

High-fidelity simulation has many potential roles in a family medicine residency. It can be an excellent tool for teaching skill development such as proper CPR technique or Glidescope^® endotracheal intubation.^1,2 Simulation use is not limited to skill development; it is also an outstanding instrument for resident evaluation.^3-5 It can be efficiently used to evaluate a resident’s performance of a complex task such as directing a team in emergent patient management.^1,6 Lastly, high-fidelity simulation can be used for system-level process improvement projects such as evaluating a hospital’s effectiveness in responding to a cardiac arrest.⁷

Technical skill development is an important part of residency education. The days of see one, do one, teach one have come and gone. Now, the expectation is that learners have a reasonable degree of technical competency before they perform procedures on live patients. This is one of the strengths of high-fidelity simulation. With the use of a high-fidelity simulator, an instructor can not only evaluate learners’ knowledge of the CPR algorithm but also provide real-time feedback on their technique, including: rate and depth of chest compressions, appropriate hand position, and even what percentage of the time the manikin’s chest returns to full recoil.

A procedure such as a Glidescope^®-assisted endotracheal intubation can be very effectively taught with a high-fidelity manikin.² The learner is presented with a patient with difficulty breathing. He first must assess the appropriateness of intubation and then proceed to obtain consent from the manikin. The learner can be taught to recognize and correct potential complications of the intubation since the manikin can be remotely adjusted to simulate a swollen tongue, immobile neck, right-main stem intubation, or pneumothorax. The task of intubating a high-fidelity manikin’s body is much more lifelike then intubating a head-only model.

Evaluation is one of the primary responsibilities of residency programs. Residencies need to evaluate their learners for specific skill development and for summative growth at multiple times during their medical training. This process is very time consuming and inherently subjective. Standardized simulation testing allows the residents to be evaluated in multiple domains simultaneously and is an excellent method to provide objective, reproducible resident evaluation.^3-5

Our program has evaluated incoming residents with standardized high-fidelity scenarios for the past 5 years. We assess the resident’s ability to take an appropriate history, detect pertinent exam findings, and diagnose and treat the patient in a timely manner. Further, we can gauge their ability to communicate with the patient and interact appropriately with family and team members. Lastly, we can determine the resident’s ability to work under pressure and adapt to changing circumstances.

An evaluation of 3 years of data (n=19) showed that our residents’ simulation performances on admission to residency was a predictor of their clinical performances in their first 6 months of training (P<.05).⁸ Using these evaluations, high-fidelity simulation can be used as an early warning sign to detect residents that are at risk for academic difficulties and allow development of an individualized remediation. We have also mapped performance scores on the simulation scenarios directly to ACGME sub-competencies. By this method, we are able to directly measure data for rating recommendations in various sub-competencies, including patient care, medical knowledge, and communication.⁹

Lastly, our residency led a multi-disciplinary quality improvement project investigating the performance of our cardiac arrest code teams on non-monitored floors. Our high-fidelity manikin was placed in a patient room, and a cardiac arrest code was paged. We were able to use our manikin to detect system breakdowns in our code response. We then developed an educational intervention that was taught with the high-fidelity manikin. When we reassessed the process, there was improvement in our deficient metrics.¹⁰

High-fidelity simulation is not just a fancy gadget but rather a valuable tool that can be used in multiple ways by family medicine residencies.

References

1. Langdorf MI, Strom SL, Yang L, et al. High-fidelity simulation enhances ACLS training. Teach Learn Med 2014;26(3):266-73.
2. Narang AT, Oldeg PF, Medzon R, Mahmood AR, Spector JA, Robinett DA. Comparison of intubation success of video laryngoscopy versus direct laryngoscopy in the difficult airway using high-fidelity simulation. Simul Healthc 2009 Fall;4(3):160-5.
3. See comment in PubMed Commons belowWendling A. Assessing resident competency in an outpatient setting. Fam Med 2002 Nov-Dec;34(10):738-4.
4. Wendling A, Baty P. A step ahead–evaluating the clinical skills of incoming interns. Fam Med 2009 Feb;41(2):111-5.
5. Fernandez G, Lee P, Page D, D’Amour E, Wait R, Seymour N. Implementation of full patient simulation training in surgical residency. J Surg Educ 2010 Nov-Dec;67(6):393-9.
6. Rodgers DL, Securro S Jr, Pauley RD. The effect of high-fidelity simulation on educational outcomes in an advanced cardiovascular life support course. Simul Healthc 2009 Winter;4(4):200-6.
7. Barbeito A, Bonifacio A, Holtschneider M, Segall N, Schroeder R, Mark J; Durham Veterans Affairs Medical Center Patient Safety Center of Inquiry. In situ simulated cardiac arrest exercises to detect system vulnerabilities. Simul Healthc 2015 Jun;10(3):154-62.
8. Klee D, Orow N, Magnatta J, Mulheron B. First year residents’ simulation testing predictive of clinical performance. A 3-year study of family medicine residents. Society of Teachers of Family Medicine Annual Spring Conference Poster Presentation. May 2014, San Antonio, TX.
9. Klee D. Resuscitation Annie on steroids: use of high fidelity simulation in resident education and milestone evaluation. Society of Teacher of Family Medicine Annual Sprig Conference Poster Presentation, April 2015, Orlando, FL.
10. Klee D, Sailor N, Vogt E, Orow. SimMan 3G MeDiC (multi-disciplinary code) project: an innovative, hospital based safety and quality improvement project. International Simulation in Healthcare Conference. Poster Presentation, January 2014, Seattle, WA.