Structural Competency in Simulation-Based Health Professions Education: A Call to Action and Pragmatic Guide.

SUMMARY STATEMENT: Simulation-based health professions educators can advance diversity, equity, and inclusion by cultivating structural competency, which is the trained ability to discern inequity not only at an individual level, but also at organizational, community, and societal levels. This commentary introduces Metzl and Hansen's Five-Step Model for structural competency and discusses its unique applicability to the metacognitive underpinnings of simulation-based health professions education. We offer a pragmatic guide for simulation-based health professions educators to collaboratively design learning objectives, simulation cases, character sketches, and debriefs in which structural competency is a simulation performance domain, alongside patient management, resource usage, leadership, situational awareness, teamwork, and/or communication. Our overall goal is to promote a paradigm shift in which educators are empowered to partner with patients, colleagues, and communities to recognize, learn about, and challenge the factors driving health inequities; a skill that may be applied to a broad range of health professions education within and outside of simulation.

Undiagnosed ventricular septal defect with resultant Eisenmenger syndrome presenting with diplopia.

Ventricular septal defect (VSD) is the most common congenital heart lesion among children. In most cases, however, it is identified and corrected in childhood, before long-term sequelae such as pulmonary hypertension develop. In this case report, we present a young man with an undiagnosed VSD with consequent Eisenmenger syndrome who initially presented to medical attention with diplopia found to be caused by cerebral infarcts.

Effectiveness of a Simulation Curriculum on Clinical Application: A Randomized Educational Trial.

INTRODUCTION: The use of simulation to develop clinical reasoning and medical decision-making skills for common events is poorly established. Validated head trauma rules help identify children at low risk for clinically important traumatic brain injury and guide the need for neuroimaging. We predicted that interns trained using a high-fidelity, immersive simulation would understand and apply these rules better than those trained using a case-based discussion. Our primary outcomes were to determine the effectiveness of a single targeted intervention on an intern's ability to learn and apply the rules. METHODS: This was a prospective randomized controlled trial. Interns were randomized to participate in either a manikin-based simulation or a case discussion. Knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool were assessed both under testing conditions using standardized vignettes and in clinical encounters. In both settings, interns completed a validated assessment tool to test their knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool when assessing patients with head injury. RESULTS: Under testing conditions, both being in the simulation group and shorter time from training were independently associated with higher score under testing conditions using standardized vignettes (P = 0.038 and P < 0.001), but not with clinical encounters. CONCLUSIONS: Interns exposed to manikin-based simulation training demonstrated performance competencies that are better than those in the case discussion group under testing conditions using standardized vignettes, but not in real clinical encounters. This study suggests that information delivery and comprehension may be improved through a single targeted simulation-based education.

Low Concordance Between Pediatric Emergency Attendings and Pediatric Residents for Predictors of Serious Intracranial Injury.

OBJECTIVES: Minor head trauma is a common cause of pediatric emergency room visits. The Pediatric Emergency Care Applied Research Network head trauma clinical decision rules (PECARN-CDR) are designed to assist clinicians in determining which patients require imaging. However, only minimal data are available on the accuracy of residents' assessments using PECARN-CDR. Prior research suggests that trainees often come to erroneous conclusions about pediatric head trauma. The objective of the present study was to assess concordance between pediatric residents' and attending physicians' assessments of children with low-risk head trauma, with the ultimate goal of improving education in pediatric trauma assessment. METHODS: This is a retrospective cohort study analyzing concordance between pediatric residents and pediatric emergency attendings who provided PECARN-CDR-based evaluations of low-risk head injuries. It is a planned subanalysis based on a prospectively collected, multicenter data set tracking pediatric head trauma encounters from July 2014 to June 2019. RESULTS: Data were collected from 436 pediatric residents, who encountered 878 patients. In the case of patients younger than 2 years, low concordance between residents and attendings was observed for the following elements of the PECARN-CDR: severe mechanism (κ = 0.24), palpable skull fracture (κ = 0.23), Glasgow Coma Scale (GCS) score less than 15 (κ = 0.14), and altered mental status (AMS; κ = -0.03). There was moderate to high agreement between residents and attendings for loss of consciousness (κ = 0.71), nonfrontal hematoma (κ = 0.48), and not acting normally per parent (κ = 0.35). In the case of patients older than 2 years, there was low concordance for signs of basilar skull fracture (κ = 0.28) and GCS score less than 15 (κ = 0.10). Concordance was high to moderate for history of vomiting (κ = 0.88), loss of consciousness (κ = 0.67), severe headache (κ = 0.50), severe mechanism (κ = 0.44), and AMS (κ = 0.42). Residents were more conservative, that is, more likely to report a positive finding, in nearly all components of the PECARN-CDR. CONCLUSIONS: Resident assessment of children presenting to the ED with minor head trauma is often poorly concordant with attending assessment on the major predictors of clinically important traumatic brain injury (abnormal GCS, AMS, signs of skull fracture) based on the PECARN-CDR. Future work may explore the reasons for low concordance and seek ways to improve pediatric resident education in the diagnosis and management of trauma.

Vertical nystagmus as isolated presentation in a patient with new diagnosis of multiple sclerosis.

Multiple sclerosis (MS) is a progressive demyelinating disease of the central nervous system with a wide array of symptoms. We present a healthy young woman who came to the Emergency Department with two days of isolated vertical nystagmus and was subsequently diagnosed with MS on imaging. Although bilateral vertical nystagmus is not a common presentation of MS, its presence should prompt inclusion of this disease process in the differential diagnosis.