Introduction :
Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education. Each month we publish a case and link a paper with associated questions for discussion. Inspired by the ALiEM MEdIC series, we moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field.
The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post! Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience. We look forward to hearing from you.
The Case :
Hiro internally sighed as he walked into the emergency department and noted an impeccably dressed young woman sitting meekly in the corner of the department. Her body language and facial expression combined to imply she was attempting to fade into the background through sheer force of will. It was a look he recognised with resigned familiarity. He’d forgotten it was the start of the new med student term.
It wasn’t that he disliked teaching. He loved teaching. But there were patients that needed reviewing, residents needed to present their cases and this morning’s handover had suggested some particularly challenging conflicts awaited him in short stay.
Until someone provided him with a resource to achieve those things, teaching would have to wait.
The Article :
Discussion :
Service provision vs teaching time is not an infrequent dilemma for bedside educators and healthcare professions in time and resource limited settings. While many of us may be tempted like Hiro to avoid interaction in the pursuit of perceived ‘higher duties’, we are making a decision that comes with significant opportunity cost.
In this month’s open access paper from advances in simulation, Viggers et al explore their experiences incorporating med students into the healthcare simulation workforce.
We look forward to your perspectives on the article, and on the challenges and benefits from working with students of all professional domains within your simulation service.
My favourite podcast yet from simulcast. Thank you thank you thank you.
I am still on my journey of learning and have been a medical student on Vic’s simulation rotation. I cannot agree more with what was discussed in this podcast. From my perspective, as a junior doctor, I could still learn so much more from simulation rotation as it gave me the greatest learning autonomy. The culture and the role modelling from the simulation rotation enabled me to hit my rotations confident that learning and education and teaching where all on me. That all of these facets alongside reflection are key to getting the most out of my day, my learning, my interactions.
I hope one day soon it’s integrated into medical schools much more. We are all different learners, educators and thinkers. Autonomy allows us to find our weaknesses safely and strengthen our strengths. It allows us to learn the way in which is best for us at that time.
Hi Melissah, thanks so much for starting the conversation this month, and how wonderful that it starts with somebody who has been a med student on a simulation rotation!
I’m wondering if you could tell us a bit more about how the rotation effected you. You mention ‘the culture and role modelling from the simulation rotation enabled me to hit my rotations confident that learning, education and teaching were all on me.”. It sounds like your experience in sim helped you feel more confident driving your own learning?
Ben
You’re right. It gave me a lot of confidence to navigate my own learning journey.
My three young children self-direct their learning daily. As parents we tend to have to ‘go with the flow’. I believe as long as we are their to 1. encourage them to attempt new skills 2. priase them for attempting it at all, and 3. chat about how they might do things differently, they can achieve anything at their pace.
To me it is much the same as a medical student. We already know what we are inherently good at and what we need to work on. This is either through self-reflection or implicit or explicit communication from supervisors and colleagues. (i’m sure there’s many more facets to this). We aren’t given the opportunity to show or understand what we are capable of when the curriculum is laid out in front of us and we can’t necessarily dive deeper into the subjects we are inherently drawn to. It wouldn’t necessarily work with mt kids if I dictated to them what they were going to learn each day. I can so easily see the tantrums and the mental strain that would have on me and the kids.
The culture of the simulation rotation was education in any shape or form. It was a safe environment to learn. By this I mean, I was able to ask questions freely and at any time to any level of supervisor. The staff treated us like we were staff. The team sat down and ran us through the many facets that is sim. They allowed us to choose our areas of interest, we were offered workshops, professional development. I found myself naturally gravitating to areas of interest, like the specifics of setting up a simulation. It gave me great insight and appreciation for the work my supervisors had put into my education. If we tired of one area, we were always allowed to move to somewhere new or focus on a different task. We could be as little or as engaged as we were comfortable. I was encouraged to learn, it didn’t matter if I was successful at a task or not as long as I gave whatever I was attempting a go.
This role modelling, this culture and this simulation team were always striving to do better. I easily walked away from their being more confident in my learning capacity and also how I learn.
Interesting! So the main takeaways from your simulation rotation weren’t necessarily about simulation per se, but more specifically about learning and culture?
Could a clinical rotation achieve this if their workplace culture was similar, or do you think the fact that the primary driver of the unit you were in was learning meant those LO’s were more successfully achieved?
What a great article and podcast this week! I work as an education fellow at the Gold Coast and would like to share an experience I had that illustrates many of the key points in the article…
At our institution we run ED sims for registrars and nurses concurrently at two sites. We normally have an expert Sim Team that does a huge amount of background organisation as well as setting up and running the tech for the sim. On this day the Sim Team member was sick so the options were to cancel the sim or to take a gamble and run it with 2 new Medical Students only 2 weeks into their Med Ed Sim rotation.
We opted to run the sim and in the set-up had problems with a change of venue, absent administration staff and a treasure hunt to try and find keys and access to set up the lab. The medical students we able to trouble shoot, work around problems, improvise and pull things together to enable the sim to run fantastically. They were even able to help out with the tech to the point were they appropriately adjusted blood pressure in response to boluses of metaraminol!
It was stressful and not without risk however following the sim it was clear that the medical students not only provided an excellent service but they also gained a huge amount personally in areas that are often referred to as the “hidden curriculum”.
I feel the reason we were able to pull off the above example is due to the huge amount of effort out Sim Team leader Vic Brazil has put into the program. The medical students had great orientation into the program and they had early exposure into a welcoming and diverse community of practice with a strong emphasis on faculty development.
It seem clear that the Copenhagen Academy for Medical Education and Simulation (CAMES) described so nicely by Sandra Viggers and our own centre on the Gold Coast are positive deviants from the average sim centre. I wonder if without the structure, support and positive mentoring provided in these centres the same medical student benefits would still be gained?
G’day Warwick,
Thanks so much for commenting this month and sharing such a positive experience of med student engagement.
Sounds like there was value for all involved. I agree with you that CAMES and Gold Coast are ‘positive deviants’ from most sim centres, and I hear you note structure, support and positive mentoring as key components to the institutions’ success with these programs.
I wonder if I could flip the conversation on its head a little bit and ask about potential barriers and challenges involved in the process as well?
If this is such a great initiative, why don’t more of us do it?
Hi Ben, I am very late to join in with this month’s posts, but had an idea to share which contributes to this conversation and although probably not unique, adds to the really interesting perspectives shared by Viggers et al, 2020. For a few years now we have invited small numbers of our undergraduate (UG) medical students to be part of the delivery of a ‘sim fac-dev’ course we run for a diverse group of local and international participants from a variety of specialities and healthcare professions. The design of our sim fac-dev course required those attending to work in small groups to develop, perform and debrief a simulation and then to engage in a meta-debrief with fellow participants and ourselves. This approach would require the course participants to take the role of the learner in a simulation they had helped to create or ask the course tutors to be the learner and this is something we have found a realism challenge. So in order to help create authentic learning experiences for this group we invite our UG students to join in as themselves, medical student’s midway through their degree to facilitate teaching opportunities for the novice faculty. The UG students we engage for this are from a cohort of students who are talking time out of their Medical undergraduate programme of studies to do an intercalated BMSc in Medical Education. So amongst the benefits for them is that they are experiencing an aspect of simulation and medical education through an educator lens, as well as acculturating and learning in the ways Melissa and Warwick describe.
In the most recent run of this sim fac-dev course, we had a conversation with the participants which got us thinking about doing some research in this area, and about the perceived opportunities, benefits and challenges for sim fac-dev and UG participants alike in asking our UG students to be involved in this way. We heard arguments for and against this approach, and discussed the potential risks to psychological safety acknowledging concerns both from the novice faculty and UG student’s viewpoints. We have only received positive feedback for all involved. We had conversations about whether we enhanced the teaching opportunities and created additional opportunities to explore the notions of realism and fidelity discussed by Dieckmann et al, 2007 and cited in Viggers article.
Not being aware of a body of similar research, we were interested to read this paper, which has helped us think more deeply about the ways in which we do and could varyingly engage the UG students as helper, operator, confederate, and teacher even further. Thanks for sharing the paper and I look forward to your insights in reply Susan (Neil & Ross).
Hi Susan, Neil and Ross,
Thanks so much for coming along to this month’s journal club and sharing your experiences!
The combination of your under-graduate med students with a faculty development program sounds like a great way to engage them in multiple levels of learning. I’m sure they would learn much from the day and the discussions that take place, and I love that they could also potentially learned from a sim targeted at their level at the same time.
You mentioned Dickemann et al’s 2007 article on fidelity and realism, would you be able to explain to us why that one resonates to you specifically in regards to the med student experience?
Hi Ben thanks for the reply and question and the reason this article resonates is, first of all, we recommend it as a key reading to our simulation course participants as a ‘deep-dive’ into theory and once they emerge from reading it, and have a strong coffee!, we spend a bit of time considering the concepts it raises and push the boundaries of their understanding of fidelity and realism. So first we encourage debate about scenario design and the notion of fidelity as more than a spectrum of high to low and challenge the tenacious impression that hi-fi equates with hi-tech, which I think I have seen you write about here as well? So it’s not a new idea to most, but what many have not read about is the descriptions of modes of thinking about realism – physical, semantic and phenomenal which the article raises. The latter is where our students come in because, in our experience, they make the simulation feel more like a real teaching and learning experience for the faculty in the circumstances of our course. This authenticity is in contrast with asking peers to “modulate” and enact the role of the learner for the purpose of briefing, delivering and debriefing a simulation when their “cognitive and social primary frame” is not that of the proposed learner in this context. I am writing this off the cuff so I hope it makes sense and am happy to be challenged if I am ‘havering’ a Scottish word for talking nonsense! Susan
Hi there! Sorry I’m late to the party. Jenny Rudolph tagged me in Twitter about this article, and I thought I would hop over here to add my last-minute 2 cents for this month’s journal club. Hope it’s not too late.
I think the authors did a great job writing about the different medical student roles at their sim center, and the mutual gains that can result from this arrangement. It’s especially interesting to me to see that towards the end of the article, the authors wrote about how the exposure to sim provides the opportunity to develop metacognitive skills, where students can gain insights into how to learn based on witnessing other students’ learning process. Although it’s not 100% clear whether these opportunities were created by design, or occurred as unintended but positive consequences of working at the sim center?
I can also add another perspective that hasn’t been mentioned: this article hasn’t really touched on the potential dark side, or at least potential pitfalls, of this arrangement. Over the years I learned from colleagues who are more expert administrators than I am that great ideas like this need to have a sound administrative and management structure to help anticipate and mitigate the multiple risks that come with any operations. Obviously each institution has its unique culture, circumstances, and challenges, and institution leaders have to evaluate each situation in context to determine whether benefits outweighs the risks in each case. Here are several potential pitfalls, there are others:
Learning dynamics risks: In what ways do having fellow students/peers as operators/teachers/embedded simulated persons affect the dynamics of the sims and debriefings? I think it will be useful to fully articulate the impact, and proactively manage them.
Student perception of privacy risks: The US has FERPA laws to protect student privacy, and sim centers employing student workers need to be in compliance. While law compliance is one dimension, another facet to consider is: in what ways would student sim participants perceive the risks to their own privacy when their peers have access to the educational records of other students? For example, if student sim participants know that student workers can log on to the sim center LMS and see the OSCE scores of other students, would the sim participants feel their privacy is threatened? The student workers can be in perfect compliance with the law, but yet student participants can still feel a threat to their privacy. And if a student sim participant raises their concern, how will it be handled from an administrative perspective? Should there be a formal process for students to voice their privacy concerns? What are the ways for sim leaders to anticipate and mitigate these risks? There may not be a lot of complaints, but many times in operations, a very small number of complaints can lead to arrangements being suspended or ordered to cease. Many universities don’t want any negative publicity or perceptions. Probably prudent to have the risks fully considered, and the process vetted through the proper channels.
Student perception of fairness risks: Being a worker at the sim center offers students an opportunity to be an “insider” in the education process. However, this can potentially introduce a risk that non-worker students would perceive that student workers have an unfair advantage that students have insider knowledge of the cases, the debriefing, the specific student assessment questions, etc., and perceive it as conferring an unfair advantage. It’s more about the perceptions and the risks that come along with the perceptions. Again, if a student raises a fairness concern, how will it be handled to mitigate the pitfalls?
There are other risks about hiring, firing, the impact of having so many inexperienced works on the operations, etc. probably too much to include here. I will just say that I know for myself, that as an educator, I don’t necessarily have the training or experience to navigate these administrative and management issues alone. I’ve learned over time that educators and students will all benefit when we collaborate with an administrative partner when we design and implement these types of programs.
Hello Grace!
Thank you so much for coming along and answering Jenny’s call :p
It feels like it’s been way too long since I got to briefly meet you and share a drink in San Antonio!
I’m glad you’ve joined us because you’ve moved the conversation to some important places we hadn’t considered or addressed yet. There’s been a lot of positive feedback from faculty and students alike about the good stuff, but you highlight potential risks of the potential power dynamic shift of students engaging with university/simulation faculty.
I’m wondering if there are some stories behind your concerns (might need another drink for that), but to me your summary of the importance of engaging with administrative partnerships and ensuring these things have been considered is a really important one.
I would be keen to open these thoughts up to the rest of the group… have these concerns played out within your service, and have you learned any mitigation strategies in reaction to that?
Hi Ben! It almost feels like traveling to conferences or sharing drinks with friends and colleagues was a thing we did centuries ago! I certainly hope we can share drinks again in the future, whether in person or virtually!
Thank you for your comments. Fortunately, I haven’t had any negative experiences specifically related to students working at the sim center. At our center in NYC, we’ve had wonderful win-wins with workers who were/are health profession students (or pre-med/pre-nursing students). However, it is probably important to note that they did not attend our university. Perhaps this approach could be a risk mitigating strategy.
However, one of the things that did help me grow the habit and (limited) skills to think about risks was having had students express concerns/complaints about things that I never even thought about. I will not share the specifics here, but each time, it was a stressful and frustrating experience. On the plus side, these experiences did help me remember to proactively anticipate the risks, and develop strategies to mitigate them.
I am also eager to hear other folks’ thoughts and experiences with this topic!