We’ve all had to get a bit creative over the past few weeks. COVID-19 has ushered in an era of not only pushing healthcare workers and hospitals into uncharted territory, but also challenging the structure and delivery of medical education. Simulation education is one of many teaching modalities that is affected by this change given its case-based, in-person structure with a team of learners. These characteristics unfortunately violate the 6-foot rule of social distancing. While traditional simulation is not typically conceptualized as a virtual modality, many of its principals can be successfully adapted for remote learning.

As clinician-educators turn their attention to learning about this virus and caring for critically ill patients, a group at risk of falling through the cracks is student learners. Most medical students have been dismissed from their clinical rotations, leaving them to find ways of learning core content outside the walls of the hospital. While students should absolutely be dismissed to minimize potential exposure, we can still aim to deliver educational content that retains features of patient care.

We know that simulation-based medical education offers an experiential learning opportunity that may increase students’ understanding of the curriculum, as well as comfort with their clinical approach.1-3 In addition, simulation can serve as a psychologically safe setting to practice the application of students’ knowledge.4  For clerkship students, core skills include conducting a history and physical, developing a differential, and proposing a plan for common chief complaints, so why not create a virtual setting in which they can get this practice through simulation?  A recent study comparing telesimulation to standard simulation showed no difference in assessment scores or favorability of the modality.5 In another study, remote facilitation showed similar performance improvement in learners to on-site facilitation.6 Teleconferencing has even been used to successfully teach skills such as the FAST exam remotely.7 Perhaps the in-person nature is not as essential as one might assume in providing effective simulation education.

Someday, students at home will be able to pop on their med-school borrowed Oculus headset and join their instructor in a pre-written case, but at this point we are a few years away from that level of Virtual Reality (VR) availability. In the meantime, we can make virtual simulation work with minimal adaptations. I co-teach a course for core emergency medicine clerkship students that was halted when group gatherings were restricted, so we moved to a Zoom platform. To preface, these cases were similar to our curriculum cases and used for learning and discussion, not assessment. That distinction is important because it would be unfair to evaluate students in a modality they have never used before. The virtual structure likely works best for clerkship-level students who have mastered the history and physical exam, and are instead focusing on the cognitive skills of developing a differential, ordering a diagnostic workup, and proposing treatment plans. What follows is a brief description of the approach and tools I recently used to carry out this session for 4th-year emergency medicine required clerkship students during a 3-hour session.

Setting: Zoom

Student rotators and myself both called in from home using Zoom. This program has features such as screen sharing that make it easy to transition back and forth between PowerPoint media and a debrief discussion. By enabling the annotation feature, you can perform many of the same things listed in step #5 without using a different application.

Cases: Patient and monitor represented

The cases used were nearly the same as those executed during the typical in-person simulation sessions for the required clerkship. To represent the patient I used a Styrofoam head dressed in headwear and an outfit. The monitor was next to the head of the patient. Both of these were oriented in front of my laptop webcam so that the participants’ screen showed only the patient and the monitor. The student spoke directly to the patient and I served as the patient’s voice. I also acted as other potential confederates, such as a bedside nurse or a consultant when needed. The student leader was instructed to explicitly state who they were addressing in order to minimize confusion during the case.

Social Distancing

Student’s view

Monitor: SimMon

SimMon is an easy-to-use application for tablets and smartphones that costs approximately $23. Two devices on the same WiFi channel are needed to use it as a remote monitor, but a single purchase will install on multiple devices with the same linked account. It shows live telemetry to mock an actual monitor. Vital signs displayed include heart rate, oxygen saturation, blood pressure, respiratory rate, end-tidal CO2, and temperature. The vital signs can be manipulated on the phone and will immediately adjust to be seen on the tablet. I used my iPhone from behind the laptop to control vital signs on the iPad to represent real-time changes during the case.

Social Distancing

Using SimMon to display vitals on an iPad

Media: PowerPoint

During the in-person simulation sessions, media was typically displayed on a screen in the simulation room. That same media was utilized during these cases. The media included labs, EKG, x-rays, and CT scans, which for convenience had been gathered into a single PowerPoint document. When the student ordered lab studies, I used the screen sharing feature on Zoom to display the requested study, and then turned off the feature to return to the patient view.

Debrief: InVision

This is a free resource that can act as a shared whiteboard. We started off the debrief with all participants on video with microphones enabled. As the discussion moved to concepts like differentials and core content, the screen was moved to the shared whiteboard for the student or instructor to write out thoughts during the discussion. Both have access to writing on the shared whiteboard. As mentioned in #1, if the annotate feature is available in Zoom, InVision might be redundant as text and drawings can be made on a PowerPoint slide instead. One advantage of the annotate feature in Zoom is the ability to point out findings on the EKG tracing by circling significant findings.

Option for voice modification: Live Voice Changer App

This is an additional piece of technology to consider, in order for the instructor to change the voice of the patient to better match age or gender profile. The instructor can speak into his or her iPhone with headphones and a speaker closer to the computer will allow for real-time voice changes for the students to hear. I opted not to use this for the session due to the need to frequently reset the monitor. If the SimMon application is not actively open for a minute it will close out on the iPad, meaning that the monitor would have to be reset each time. A separate device could be used for the Live Voice Changer App to remedy this. Additionally, I reached out to the app developers of SimMon, and the next version should not have this issue.

Final thoughts for a smooth session

  • The pre-brief is essential and should include explicit expectations for the virtual simulation and how it differs, for example, minimal team-based interaction, absence of props, and lack of a physical exam.
  • Assign one individual to lead the case, but provide ways for other participants to be involved and called upon for specific contributions.
  • The student should talk directly TO the patient as they normally would to obtain the history. The instructor can also play the role of the bedside nurse, but the team leader should be clear about when they are addressing the patient or the nurse.
  • The desired elements of the physical exam must be asked for by the leader, similar to an oral board
  • Physical examination is a limitation of simulation in general, but more so when conducted over video. I would recommend against cases that require a thorough neurologic exam or skin findings, unless a picture or video can be provided.
  • Describe the expected endpoint for the case (for example, disposition) so that the student knows what he or she is working toward.
  • Whenever possible, during the debrief ask questions directed toward specific individuals to avoid diffusion of responsibility on video conferencing.
  • It should be required that students are on-video and off-mute to encourage full engagement.

Best of luck keeping simulation accessible to our student learners during this challenging time!

Check out ALiEM’s other great remote educational content

References:

  1. Sperling JD, Clark S, Kang Y. Teaching medical students a clinical approach to altered mental status: simulation enhances traditional curriculum. Med Educ Online. 2013;18:1-8. PMID: 23561054
  2. Solymos O, O’Kelly P, Walshe CM. Pilot study comparing simulation-based and didactic lecture-based critical care teaching for final-year medical students. BMC Anesthesiol. 2015;15:153. PMID: 26490826
  3. Vattanavanit V, Kawla-Ied J, Bhurayanontachai R. High-fidelity medical simulation training improves medical students’ knowledge and confidence levels in septic shock resuscitation. Open Access Emerg Med. 2017;9:1-7. PMID: 28053558
  4. Weller JM. Simulation in undergraduate medical education: bridging the gap between theory and practice. Med Educ. 2004;38(1):32-38. PMID: 14962024
  5. McCoy CE, Sayegh J, Rahman A, Landgorf M, Anderson C, Lotfipour S. Prospective Randomized Crossover Study of Telesimulation Versus Standard Simulation for Teaching Medical Students the Management of Critically Ill Patients. AEM Educ Train. 2017;1(4):287-292. PMID: 30051046
  6. Ohta K, Kurosawa H, Shiima Y, et al. The Effectiveness of Remote Facilitation in Simulation-Based Pediatric Resuscitation Training for Medical Students. Pediatr Emerg Care. 2017;33(8):564-569. PMID: 27261952
  7. Poland S, Frey JA, Khobrani A, et al. Telepresent Focused Assessment With Sonography for Trauma Examination Training Versus Traditional Training for Medical Students: A Simulation-Based Pilot Study. J Ultrasound Med. 2018;37(8):1985-1992. PMID: 29388234

 

Ashley Rider, MD

Ashley Rider, MD

Clinical Instructor and Simulation Education Fellow
Stanford Department of Emergency Medicine
Ashley Rider, MD

@ac_rider

Simulation Education Fellow, Stanford EM. Proud grad Highland EM ‘19 and BCM ‘15. Making every day count. Tweets my own.