Intensive simulation versus control in the assessment of time to skill competency and confidence of medical students to assess and manage cardiovascular and respiratory conditions—a pseudo-randomised trial

The traditional apprenticeship model of medical education is being challenged by multiple factors, including changes to medical school curricula, patient demographics, acute hospital workflow and senior clinician availability [1]. The breadth of medical student education often depends upon the number of ‘teaching cases’ available on the ward during a student’s term. The traditional ‘See one, do one, teach one [2]’ method occurs in an uncontrolled teaching arena and is associated with an unacceptable patient risk. New curriculum models and increasing student numbers are further stretching resources and resulting in decreased clinical time with patients. Acutely unwell patients and those with ‘clinical signs’ have decreased lengths of stay in hospital, resulting in potentially less exposure to these clinical signs for students and a subsequent reduction in valuable educational resources. Increasing demands upon senior clinicians are reducing the exposure of students to them. Senior clinicians rarely have the opportunity to observe a student moving through the following stages with a single patient’s history, examination, diagnosis and planning. Newly qualified doctors often struggle not with knowledge but with application—the approach to the undifferentiated sick patient, communication skills in the workplace and decision-making. Evaluation of new doctor performance is difficult and not standardised [1–4].

The Australian Medical Council noted that ‘(t)he challenge for all medical schools is to develop a curriculum which, while not neglecting the transmission of factual knowledge and practical skills, also stimulates enquiry, develops analytical ability and encourages the development of desirable professional attitudes in the students’ [5]. The Clinical Placement Enhancement Program (CPEP) course was designed to use a variety of interactive education modalities, including simulation, to optimise the delivery of two core medical school subjects—cardiovascular and respiratory medicine.

Simulation-based education is increasingly being used in healthcare including in the areas of patient safety and the development of procedural and clinical skills. Educational theory provides a basis for how simulation can be utilised in medical education. A simulator is a training device that artificially duplicates the conditions likely to be encountered in a particular situation. Simulation involves the operation of that training device over time [6]. In the setting of medical education, the simulator usually involves a mannequin (full size or part task training device) in an environment designed to mirror that which would be encountered by the student or doctor in real life. The simulation is run with the patient exhibiting symptoms and signs of a clinical condition, and the participant is required to work through the assessment, diagnosis and management of this condition. This is usually combined with a debrief, which is a guided reflection upon the behaviour during the simulation and an opportunity to discuss both strategies for improved performance and fill in any knowledge gaps that have been identified [7–11].

The two educational models adopted to underpin this project were Kolb’s learning model and Bloom’s taxonomy. Kolb’s model demonstrates how a cyclical learning model involving experience, reflection, conceptualisation and reapplication mirror the staged processes often incorporated into simulation-based education [12]. In the first stage, the simulation provides the ‘concrete experience’. The student interacts with the simulated patient and clinical staff (confederate acting as a nurse) in a realistic clinical environment. A debrief occurs in the second stage where the students reflect on their own experiences and those that they have observed. During the third stage, ‘forming abstract concepts’, the facilitator provides the students with concepts and assists in providing opportunity for conceptualization. The fourth stage, ‘testing in new situations, experimentation’, is a chance for the students to go back and repeat the simulation, with the unlimited opportunity to try things differently without the fear of harming patients. In single-task simulations, this takes the form of full repetition, with the expert facilitator guiding the feedback towards improved technical performance. In high-fidelity, immersive simulations, which have more variables and are logistically more difficult to replicate, the repetition often takes the form of recurring behavioural themes such as ‘calling for help’ or ‘allocation of roles’ [13, 14]. The twelve simulated clinical scenarios and subsequent debrief with senior clinicians in CPEP used this theory as a model for teaching.

Bloom’s taxonomy is viewed as a hierarchical schema of learning. Simulation-based education aims to fit into the educational model [15]. The accumulation of knowledge and facts occurs prior to the simulation. The expectation of a baseline level of knowledge is often assumed, but as noted above, the simulation offers an opportunity to identify knowledge gaps in participants. At the ‘application’ level, students use their knowledge in a new situation, having previously acquired this knowledge in an abstract setting. At the ‘analysis’ level, students apply critical thinking to a realistic clinical situation. At the ‘synthesis’ level, students have the opportunity to think creatively in a clinical environment.

The CPEP is a 4-day immersive simulation course, delivered in the first week of cardiac and respiratory medicine clinical rotations for final year medical students. The CPEP course was designed to integrate patient safety and professionalism teaching into a simulation course based around the core topics of cardiovascular and respiratory medicine, using adult learning principles and proven educational theory.

The aim of this study is to assess the effectiveness of the CPEP [16, 17]. Specifically, this paper addresses the following research questions:

1. 1.

   Does the CPEP result in competency outcomes that are at least equivalent to those achieved through a standard 6-week teaching programme?

2. 2.

   Does the CPEP lead to an improvement in students’ confidence in assessing and managing patients with cardiovascular and respiratory conditions?