Association of Simulation Participation With Diagnostic Reasoning Scores in Preclinical Students.

PURPOSE: The aim of the study was to evaluate for an association between the number of voluntary mannequin simulation sessions completed during the school year with scores on a year-end diagnostic reasoning assessment among second-year medical students. METHOD: This is retrospective analysis of participation in 0 to 8 extracurricular mannequin simulation sessions on diagnostic reasoning assessed among 129 second-year medical students in an end-of-year evaluation. For the final skills assessment, 2 physicians measured students' ability to reason through a standardized case encounter using the Diagnostic Justification (DXJ) instrument (4 categories each scored 0-3 by raters reviewing students' postencounter written summaries). Rater scores were averaged for a total DXJ score (0-12). To provide additional baseline comparison, zero participation students were divided into 2 groups based on intent to participate: those who signed up for extracurricular sessions but never attended versus those who never expressed interest. Scores across the attendance groups were compared with an analysis of variance and trend analysis. RESULTS: The class DXJ mean equaled 7.56, with a standard deviation of 2.78 and range of 0 to 12. Post hoc analysis after a significant analysis of variance (F = 4.91, df = 8, 128, P < 0.001) showed those participating in 1 or more extracurricular sessions had significantly higher DXJ scores than those not participating. Students doing 7 extracurricular sessions had significantly higher DXJ scores than those doing 0 and 2 (P < 0.05). Zero attendance groups were not different. A significant linear trend (R = 0.48, F = 38.0, df = 1, 127, P < 0.001) was found with 9 groups. A significant quadratic effect, like a dose-response pattern, was found (F = 18.1, df = 2, 125, P < 0.001) in an analysis including both zero attendance groups, a low (1-4 extracurricular sessions) group and a high (5-8) group. CONCLUSIONS: Higher year-end diagnostic reasoning scores were associated with increased voluntary participation in extracurricular mannequin-based simulation exercises in an approximate dose-response pattern.

Optimizing Multidisciplinary Simulation in Medical School for Larger Groups: Role Assignment by Lottery and Guided Learning.

PURPOSE: Medical school simulations are often designed for a limited number of students to maximize engagement and learning. To ensure that all first-year medical students who wished to join had an opportunity to participate, we designed a novel method for larger groups. PATIENTS AND METHODS: We devised a low technology "Orchestra Leader's" chart approach to prominently display students' roles, chosen by lottery. During simulation, the chart was mounted on an intravenous pole and served as a group organizational tool. A course instructor prompted students using the chart to accomplish the course objectives in a logical order. Real-life cardiologists and gastroenterologists provided the students with expert subspecialty consultation. We analyzed 125 anonymous student evaluation ratings for 3 years (2017-2019) with a range of 8 to 19 students per laboratory session. RESULTS: Our 2017-2019 larger group sessions were all rated as excellent (1.26, Mean, SD ±.510) on the Likert scale where 1.0 is excellent and 5.0 is poor. There were no statistically significant differences in overall ratings among the 2017, 2018 and 2019 sessions. The subspecialists were uniformly rated as excellent. Verbatim free-text responses demonstrated resounding student appreciation for the role assignment by lottery method. CONCLUSION: We designed a novel, "Orchestra Leader's" chart approach for accommodating larger groups in a multidisciplinary simulation laboratory using role assignment by lottery, roles depicted on an organizational chart, and expert instructor prompting. Our consistently excellent ratings suggest that our methods are useful for achieving well-rated larger group simulation laboratories.

Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns.

PURPOSE: The correlation between simulator-based medical performance and real-world behavior remains unclear. This study explored whether the effects of extended work hours on clinical performance, as reported in prior hospital-based studies, could be observed in a simulator-based testing environment. METHOD: Intern volunteers reported to the simulator laboratory in a rested state and again in a sleep-deprived state (after a traditional 24- to 30-hour overnight shift [n=17]). A subset also presented after a shortened overnight shift (16 scheduled hours [n=8]). During each laboratory visit, participants managed two critically ill patients. An on-site physician scored each case, as did a blinded rater later watching videotapes of the performances (score=1 [worst] to 8 [best]; average of both cases=session score). RESULTS: Among all participants, the average simulator session score was 6.0 (95% CI: 5.6-6.4) in the rested state and declined to 5.0 (95% CI: 4.6-5.4) after the traditional overnight shift (P<.001). Among those who completed the shortened overnight shift, the average postshift simulator session score was 5.8 (95% CI: 5.0-6.6) compared with 4.3 (95% CI: 3.8-4.9) after a traditional extended shift (P<.001). CONCLUSIONS: In a clinical simulation test, medical interns performed significantly better after working a shortened overnight shift compared with a traditional extended shift. These findings are consistent with real-time hospital studies using the same shift schedule. Such an independent correlation not only confirms the detrimental impact of extended work hours on medical performance but also supports the validity of simulation as a clinical performance assessment tool.

Long-term educational impact of a simulator curriculum on medical student education in an internal medicine clerkship.

BACKGROUND: Medical simulation is frequently used in postgraduate medical training, but its value and sustainability in medical student education are less clear. We report the first long-term experience of mannequin simulation in an internal medicine clerkship. METHODS: During a 6-year period (2002-2009), 327 Harvard medical students participated in a simulator-based teaching experience designed to expose students to the principles of myocardial infarction (MI). This experience was additive to a 12-week clerkship curriculum. Through blinded survey instruments, we sought to determine how the simulator exercise modified student exposure to a core curricular objective in the traditional clerkship. We also sought student and faculty perception of this educational tool and factors important to sustainability. RESULTS: Three hundred twenty-seven consecutive students were exposed to the simulation exercise and their experiences evaluated. Three hundred twenty-six students (99%) described the simulation experience as valuable, with >69% requesting multiple sessions be provided during each clerkship. Although a core objective, only 78% of students reported having a didactic teaching session on MI during the clerkship, and only 47% of students reported exposure to a live patient with MI. Furthermore, only 15% of students reported exposure to at least two different clinical presentations of MI, allowing comparison and reflection. Thus, the simulation exercise provided the only exposure to this topic for 22% of students and facilitated comparisons of different clinical presentations for 85% of students. When students participated in both the simulator and the didactic sessions, 74% favored the simulation exercise. Faculty cited small group size, once monthly delivery and focused curricula as key points for sustainability of this effort. CONCLUSION: Mannequin simulation is a valuable and sustainable addition to a third-year internal medicine clerkship. For some students, simulation provides otherwise unavailable exposure to core content material. For the majority of students, simulation also provides the only means of exposure to multiple presentations of a single illness. Together, these data strongly suggest that simulation promotes both experiential learning and comparative analysis in a clerkship setting.