1 Scottish Simulator Centre, Stirling, UK 2 Department of Anaesthesia, Royal Victoria Infirmary, Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
*Corresponding author. E-mail: david.greaves@ncl.ac.uk
A recent trend in medical education has been to replace practical instruction using real patients with a variety of simulations, ranging from communications skills stations, where trained actors play the patient, through the part-task trainers familiar in undergraduate clinical skills centres, to intermediate and high-fidelity whole-patient simulators. Another trend has been away from classical curriculum towards the use of learning objectives, defined as competencies. A clinical competence is a chunk of learning that will change the learners behaviour and that, observed as part of the learners performance, can be judged satisfactory or otherwise by the teacher. At postgraduate level, implementing the recommendations of the report Hospital Doctors: Training for the Future1 required a change in assessment philosophy towards the definition and recognition of competencies. The Royal College of Anaesthetists2 responded by introducing its competency-based scheme for training and assessment.
These two trends have come together where the need to demonstrate the ability to perform practical skills, not only in isolation but also as part of the overall management of a patient with a clinical problem, has led to a search for new solutions. One such is to teach and check competencies in a simulated environment rather than the real clinical world. Simulation in anaesthesia is not new, but the availability of lower-cost intermediate-fidelity models, such as ACCESSTM and SimManTM, and the increase in the availability of higher-fidelity simulators means that more anaesthetists are likely to be involved in using these devices as educational tools. How should they be used? Some lessons can be learned from the article by Olympio and colleagues3 published in this issue.
Olympio and colleagues3 sought to investigate the impact of teaching a novel routine for managing accidental placement of a tracheal tube in the oesophagus. They reported that on a revisit to the simulator centre, at which the learners were challenged by another accidental oesophageal intubation, they did not remember to use the revised protocol that they had been taught on their previous visit. The oesophageal intubation event was only one part of a scenario in which a much more major threat to the patients physiology occurred: either major haemorrhage or anaphylactic shock. The authors conclude that the lesser impact of the oesophageal intubation event may have contributed to the participants failure to remember the modified technique and incorporate it into their practice. They also note that the learners did not see oesophageal intubation in the real workplace between their visits to the simulator, and that this lack of repetition may have been material in the learners failure to incorporate the new oesophageal intubation drill into their practice. Their finding that the lesson they taught was not used at a subsequent crisis neither proves nor disproves the effectiveness of simulation as a teaching tool, but it does afford the opportunity to explore some of the challenges associated with the introduction of new educational technologies.
The approach adopted by Olympio and colleagues is commonly used in simulators. The learner is presented with a clinically challenging event and, by managing that case and subsequently reviewing his or her performance, can be assisted to identify areas of strength or weakness that can be used to set future learning goals. This approach is consistent with the principles of adult education.4 If learning is to be effective, the application of some other educational principles is necessary. Adult learners are more likely to learn something they perceive as being relevant to their needs. It is insufficient for the lesson to be relevant to their overall training programme; it must be relevant to the current contexts of their learning. Oesophageal intubation is a feared complication of anaesthesia. The residents participating in the scenario no doubt found the opportunity to recognize and deal with it useful and appropriate to their clinical practice. Another principle is that where theoretical learning is associated with practice, the theory must also be relevant to the practice. Intuitively, we feel that the teachers explanations and demonstrations, whether in tutorials, lectures or simulator sessions, must be consistent with what the learner is seeing in the real workplace. Curriculum is the device whereby individual items of learning are connected to form a relevant, contextual framework. Olympio and his colleagues3 had decided that, in the case of accidental oesophageal intubation, it would be safer to leave the tube in the oesophagus until a second tracheal tube was correctly placed. The clinical teachers in their institution were not teaching this approach routinely. Irrespective of the correctness of their notion, in educational terms, a dislocation between what they were teaching in simulation and what clinical teachers were teaching in the real workplace apparently sabotaged their message. It is fundamental that simulator teaching and experience must be in line with, and reinforce, real workplace experience.
How can activities used in simulation centres be integrated into the curriculum? Salas and colleagues,5 writing about the use of simulators in aviation training, recommended that they should be linked systematically with other training. This requires a curriculum that coordinates the various instructional tools used. A single curriculum must encompass real-world and simulation-based learning. Trainees report that being presented with different methods of dealing with such practical skills as airway maintenance often confuses them. Other high-reliability industries (industries where safety is paramount) make extensive use of written protocols and guidelines. These encourage consistency, because all learners are taught the same procedure. They also ensure that the same approach to a problem is adopted, however and wherever it is taught. Medicine has traditionally tended to shy away from such an approach, but the climate is changing and the use of protocols is becoming more acceptable. These apply not only to life-threatening situations, such as the management of ventricular fibrillation, but also to medical emergencies such as the management of acute asthma.6 This raises the issue of where such guidelines come from, especially for rare events. Approaches such as the Scottish Intercollegiate Guidelines Network use the evidence that is available, but approaches to the management of uncommon events may not reach this degree of rigour. Authoritative guidelines need accurate data, collected not only for adverse events but also for near misses. In this way the most appropriate techniques for dealing with uncommon emergency events can be elicited, and form the basis of tools to allow training and assessment in these situations. This would also improve the validity of simulator-based assessment, by permitting the development of fully realistic scenarios, so that performing well in simulation really would predict a high likelihood of performing well in the real world. The adoption of agreed routines as guidelines for practice permits a consistent approach to instruction in the real world and coordination of this with teaching in the simulator. Given the difficulties it is not surprising that Olympio and his colleagues3 did not have a departmental protocol for their recommended method of dealing with oesophageal intubation to apply to their simulator sessions. Nevertheless, there are techniques available for reaching initial consensus.7
A further problem for Olympio and colleagues was that the lesson relating to reintubation was less compelling than the rest of the scenario. In the context of the two scenarios, there was no benefit demonstrated that was specific to the new approach to oesophageal intubationother techniques would have been equally effective. The simulation did not call for additional complications and adverse effects in the case of the learner adopting the conventional management of the misplaced tube. To this extent the teaching did not use the full dynamic of simulation. A routine was described and the learners were encouraged to employ it. This was essentially a walk-through of the technique, such as could have been done with a part-task trainer. The incorporation of this novel learning objective within a genuine, dynamic, case-management problem was always likely to fail. The learners attention would be focused on the event with the greater shock value, where successful management would resolve the problem. This calls attention to the routines of lesson planning and the curriculum for simulator training. Not only must the routines be consistent with the learners real needs and workplace experience, but the components of the simulation must build towards the intended lesson.8 The challenges within the scenario must be suitable for the learner, both in terms of their difficulty and their number. Experienced, competent anaesthetists may easily overcome some aspects of the scenario that would confuse a relative novice. Skilled performers may benefit from juggling complex problems simultaneously, whereas novices require a less cluttered stage for their operations. Scenario overload will, at worst, confuse the learner and even a minor mismatch between the challenges may detract from the learning. This appears to be one of the factors that reduced learning in Olympios experiment.
Olympio and colleagues3 may not have succeeded in teaching a new technique, but they have shed light on some existing practices in their own institution. To close the loop it is necessary to reach a consensus with colleagues in a department that will in turn allow the trainees to have the technique reinforced during work with real patients. For the rest of the simulator community, Olympios results provide a timely reminder that simulation is just one of the ways of learning. Salas and colleagues5 wrote in 1998 that simulators were not being used to best effect in aviation training. Better results were likely to come from concentrating not on the fidelity but on a better understanding and application of the principles of training. Lessons taught in simulation must be coherent, appropriate in the context of the learners overall curriculum, and not at odds with what is being taught in the real workplace. Expertise in education and technology must go hand in hand.
References
1 Department of Health. Hospital Doctors: Training for the Future. The Report of the Working Group on Specialist Medical Training. London: Department of Health, 1993
2 Royal College of Anaesthetists. The CCST in Anaesthesia. 1. General Principles. London: Royal College of Anaesthetists, 2000
3 Olympio MA, Whelan R, Ford RPA, Saunders ICM. Failure of simulation training to change residents management of oesophageal intubation. Br J Anaesth 2003; 91: 31218
4 Knowles, M. The Adult Learner: A Neglected Species, 4th edn. Houston (TX): Gulf Publishing, 1990
5 Salas E, Bowers CA, Rhodenizer L. It is not how much you have but how you use it: toward a rational use of simulation to support aviation training. Int J Aviat Psychol 1998; 8: 197208[ISI][Medline]
6 Scottish Intercollegiate Guidelines Network (SIGN), The British Thoracic Society. British Guidelines on the Management of Asthma. Scottish Intercollegiate Guidelines Network Guideline 63. Edinburgh: SIGN, 2003
7 Glavin RJ, Maran NM. Development and use of scoring systems for assessment of clinical competence. Br J Anaesth 2002; 88: 32930
8 Byrne A, Checketts M. Practicalities of simulation: adding role-play to low and intermediate fidelity simulation. In: Greaves D, Dodds C, Kumar K, Mets B, eds. Clinical Teaching: A Guide to Teaching Practical Anaesthesia. Lisse: Swets & Zeitlinger, 2003; 24153