In this post, Dr Agata Dunsmore shares some of the teaching innovations developed by the General Practice (GP) teaching team on the MBChB. Agata is a GP teacher, Year 4 Deputy Director of MBChB and previous Clinical Teaching Fellow in Simulation.This post belongs to the Engaging and Empowering Learning: Celebrating Best Practices series.
Up until the late 20th Century, medical education has relied on the apprenticeship model where trainees were able to perform procedures on patients before they were fully competent. In the last 40 years, the drive for patient safety has moved away from this model into greater utilisation of simulation.
“Simulation is a technique – not a technology- to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world” (Gaba, 2004).
It includes a spectrum from practising a clinical skill, such as taking blood to complex scenarios involving multi-professional teams. Delivering simulation which looks real and prepares clinicians for working in the NHS, demands expensive technology and a significant amount of staff time to deliver it. Continuing to innovate and expand simulation whilst being faced with increasing student numbers has proved difficult.
The recent explosion of research into understanding the pedagogy underlying simulation has enabled educators to think more out of the box to develop experiences that promote cognitive, emotional and behavioural learning without having to recreate or mimic the clinical space. Here I will talk about three such innovations that are being used by Edinburgh University Medical School. The simulation sessions teach medical students decision-making in triaging unwell patients remotely, how to assess patients on the telephone and how to deal with diagnostic uncertainty. These provide experiential learning to medical students without the need to recreate physical spaces.
Tactical decision games
Tactical decision games (TDG) are facilitated simulations using brief written scenarios where there is uncertainty and complexity. The trainees consider options to manage the situation and subsequently, the facilitator leads discussions around the decisions made and the rationale underpinning these. The discussions also develop cognitive, personal and social resource skills which contribute to safe and effective task performance. We developed two TDGs based on the prioritisation of a duty doctor triage list in primary care and decision-making in managing a complex patient with multiple conditions in a challenging social setting. There were multiple management options with no single best answer.
Telephone consulting virtual simulation
COVID-19 necessitated a rapid shift to telephone consulting in General Practice and remains a feature now as it enables access to working, housebound or remote communities. A virtual high throughput telephone consulting simulation was developed which enables 96 students in a day to practice one telephone consultation and observe their peers do three other consults. The students receive real-time feedback from senior clinicians in small groups of four students with a facilitator. The online delivery via Teams aids the realism of remote consulting. Furthermore, recruitment of GPs was easier and it reduced the need for students to travel back to the university whilst away on placement.
Shadowbox simulation
The shadowbox simulation technique is a video-based simulation that allows learners to view a recorded scenario. It is based on the cognitive transformation theory, and allows learners to view different perspectives including that of the expert. We used the Virtual Primary Care platform which provides edited videos of actual consultations filmed for Channel 5 GP behind closed doors documentary, to run case based discussions with students. The videos can be paused for the students to consider the patient or GP perspective at pertinent points to consider decision making and to illustrate concepts such as managing uncertainty and safety netting.
Practical take-aways
There are a few key practical messages I have taken from my time as a Teaching Fellow in Simulation:
- When innovating teaching sessions, consider what is the intended learning and think more broadly about the cognitive, emotional and behavioural aspects, especially in experiential learning.
- Understand the pedagogy of the technique you intend to use. How does it fit with what you intend to teach? Can it be done in a different way but continue to offer the same degree of learning?
- Realism is not always physical; emotions and behaviours can be provoked in different ways as long as the scenarios feel authentic and the students see the value of learning.
- Evaluate what you do. People are complex and respond in unpredictable ways, sometimes there are pitfalls but occasionally unexpected gains.
References
Gaba, D. M. (2004). The future vision of simulation in health care. Quality & Safety in Healthcare, 13 Suppl 1, i2-10.
Agata Dunsmore
Dr Agata Dunsmore is a GP Teacher and Deputy Director of Year 4 on the MBChB. She works clinically as a GP in Edinburgh.
