simulation in radiology - car€¦ · linda probyn, md, frcpc eric bartlett, md, simulating real...
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Simulation in Radiology
Linda Probyn, MD, FRCPCEric Bartlett, MD,
Simulating Real Life Challenges
Disclosures
• Linda Probyn – none• Eric Bartlett – none
Learning Objectives
1. Describe various types of simulation that can be used in radiology education
2. Discuss how simulation in radiology can be used as an assessment tool to improve performance
Simulation in Radiology
• Use of simulation to train residents is ↑’ing in Medical Education
• Fewer hands on experiences:– Decrease hospital length of stay– Restrictions on duty hours– Decreased resident autonomy– Productivity pressures– Patients’ awareness of trainees “practicing” on
them
Simulation in Radiology• Simulation allows:
– Trainees to practice a procedure or scenario before doing on actual patients
– Evaluation of trainees to assess readiness for the “real world”
• Cons:– Not “exactly” the same– Can’t anticipate all scenarios– $$
Simulation in Radiology – Types
• Procedural• Nonprocedural
– Interpretative & Computer based
– Team based & Crisis Management
– Professional & Communication– Hybrid– In-situ
→ ER Sim
Acute Emergencies in Radiology
• Rare in the Radiology Dept• But Residents often first responders (esp. after
hours)• Little ability to train• Simulation useful
Acute Emergencies in Radiology
• PGY2s – 3 hour simulation– Contrast reaction– Seizure– Cardiac arrest
• Didactic lecture• Debrief
Acute Emergencies in Radiology
• Evaluation pre-, immediately post- and 1 year post-simulation
Acute Emergencies in Radiology
• Resident knowledge and comfort improved post-simulation, esp. in non-contrast reaction related simulation
• Returned to baseline knowledge 1-year post simulation
• Residents need frequent exposure to managing acute emergencies
Hybrid Simulation• More than one type of simulator used• Common to use manikin with
standardized patient
Technologist
Hybrid Simulation• Increased realism of scenario• More complex and challenging• Assess several domains
Technologist
In Situ Simulation• Simulation in clinical
environment• Close to real life
experience• Usually involves health
care team
In Situ Simulation• Reveals local system
challenges• Complex environment• Assess several domains
Simulating Real Life Challenges
‘Training mirrors practice’
‘Training mirrors practice’• CBD concept• Residency programs:
• Training curriculum• Goals/Objectives• On-the-job
• Assessments focus on ‘Medical Expert’
• Assessment gapEntrustable Professional
Act (EPA)
ACR Exam
Mock Oral
ITER
OSCE
CBD, a different type of assessment• Emergency radiology
• Challenge: how can we be sure that PGY2 residents are ready to cover after-hours on-call activities?
• On-line simulation program• Goal: address ‘challenge’ (summative assessment)
and demonstrate all tasks/components of the job that are required for a resident to be ‘competent’ at after-hours on-call work (formative assessment).
Challenge #1Demonstrating competency
in emergency radiology.
(. . . a future EPA?)[EPA = Entrustable Professional Act]
After-Hours:• Different After-Hours structures/preparation across Canada
• Ultimately, similar work:
• Residents work on PACS units to prioritize/protocol cases, interpret studies, enter preliminary diagnoses, and to record critical results reporting.
• High stress—preliminary diagnoses from residents are acted upon. Quick turn-around-time.
the simulationER SIM:
Emergency Radiology SIM:• 4-hour on-line exam (2016: PGY2-5)• Simulated a 4-hour After-Hours Shift:
• Protocol cases• Prioritize cases• Manage a worklist• View full cases• Type preliminary reports• Critical results reporting• Answer ‘pages’• Provide recommendations• Keep a log book of cases/diagnoses• Prepare a handover document
Emergency Radiology SIM:• Assessment:
• Summative—are the skills and knowledge at expected level to allow for increased role and responsibility? EPA?
• Formative—demonstration of all the tasks and skills needed to successfully complete an After-Hours Shift (an experiential ‘walk-through’ of the job).
• Articulate—Interactive e-learning software• Develop educational modules• Deliver quizzes• Create simulations• Analytics to track learners
• Vimeo—Video hosting• Used to host DICOM series
Emergency Radiology On-line Simulator Demo
Emergency Radiology SIM:
Examples: Main page
Examples: Main page
Examples: Main page
Examples: Main page
Examples: Main page
Examples: Main page
Examples: Protocol
Examples: Protocol
Examples: Protocol
Examples: Protocol
Examples: Protocol
Examples: Protocol
Examples: Paging
Examples: Paging
Examples: Paging
Examples: Paging
Examples: Paging
Examples: Paging
Examples: Prioritize
Examples: Prioritize
Examples: Protocol
Examples: Protocol
Examples: PACS Worklist
Examples: PACS Worklist
Examples: PACS Worklist
Examples: PACS Worklist
Examples: PACS Image Viewer
Examples: PACS Image Viewer
Examples: PACS Worklist
Examples: Reporting
Examples: Reporting
Examples: Reporting
Examples: Reporting
Examples: Reporting
Examples: Reporting
Examples: Reporting
Examples: Reporting
Examples: Reporting
Examples: Critical Results
Examples: Critical Results
Examples: Critical Results
Examples: PACS Worklist
Examples: PACS Worklist
Examples: Paging
Examples: Handover
Examples: Handover
the resultsFidelity & Findings:
“Fidelity” in simulation:• How closely the appearance and behaviour
of the simulation resembles reality
• contextual fidelity = psychological fidelity =
meaning/learning
Fidelity—Emergency Radiology SIM:Real Life Challenges: On-Call: ER SIM:Accept handover
Protocol cases
Prioritize cases
Manage worklist
Answer pages
View full DICOM cases
Preliminary reports
Critical results reporting
Provide recommendations
Log cases/tasks
Prepare next handover
Fidelity—Emergency Radiology SIM:Real Life Challenges: On-Call: ER SIM:Accept handover
Protocol cases
Prioritize cases
Manage worklist
Answer pages
View full DICOM cases
Preliminary reports
Critical results reporting
Provide recommendations
Log cases/tasks
Prepare next handover
Fidelity—Answering ‘pages’:Real Life Challenges: On-Call: ER SIM:
Disruption
Varied scenarios
Interpersonal interactions
Managing conflict
Managing unexpected
Dynamic interaction
Feedback
Fidelity—View full DICOM cases:Real Life Challenges: On-Call: ER SIM:
Complete DICOM
All planes/sequences
Prior imaging
Fast, seamless review
PACS toolkit
Simultaneous view/reportX
Emergency Radiology SIM Results:• Preliminary results:
• Medical Expert:• Performance improved every year, with less
profound change between PGY4 and PGY5.• Identified one PGY2 resident needing remedial work.
• Communicator—improves throughout residency.• Collaborator:
• Ability for resident to properly recommend ‘next steps’ for patient—did not improve after PGY2 year.
• Protocolling exams—relatively poor performance.• Advocate—good performance across PGY-levels.• Professional—difficult to test.
• Determining On-call ‘readiness’ (EPA fulfillment):• Excellent
• Answering ‘pages:• Poor
• View full DICOM cases:• Good—technical challenges, solutions pending
Fidelity—Overall:
Resident Feedback: Satisfaction Survey
80%
60%
90%
67%
87%
87%
86%
85%
Tips/TricksLessons Learned.
Guidance.
Bumps in the Road:• Software and Hosting packages are expensive• Dependent on 3rd party programs (Articulate, Vimeo, etc.)• Need computer lab with appropriate hardware• Dependent on properly functioning high-speed Internet
• Data overload!• Help to score cases• Develop a scoring matrix
How to make it all happen:• Team effort• Learners must see relevance
• “High Fidelity”• Resources (software, LMS)• Educational research/Scholarly activity• CBD deadlines help
• 2017—trial roll-out to other programs• Research collaboration• Unmasked some technical issues
• 2018 goals:• Rework ER Sim to address technical issues and improve
the virtual PACS, new cases and scenarios• Continue roll-out across Canada• Add qualitative component to research collaboration
Next Steps:
• Ultimate goal: • Solution to assessment gap in CBME• Better understanding of CBD before 2019 meeting
with the Royal College• Use various modes of simulation to enhance
residence skills to prepare for training and practice
Next Steps:
Questions/Comments?
#TorontoStrong
The EndLinda Probyn, MD FRCPC
Eric Bartlett, [email protected]
References• Chelten AL, Mendriatta-Lala M, Probyn L, Auffermann WF, DeBenedectis CM. et. al.
Conventional Medical Education and the History of Simulation in Radiology. Academic Radiology 2015; 22(10):1252-1267.
• Petscavage JM, Paladin AM, Wang CL, et al. Current status of residency training of allergic-like adverse events to contrast media. Acad Radiol 2012; 19(2):252-5.
• Sarwani N, Tappouni R, Flemming D. Use of a Simulation Laboratory to Train Radiology Residentsin the Management of Acute Radiologic Emergencies. ARJ Am J Roentgenol 2012; 199(2):244-51.
• Tofil NM, White ML, Grant M, et al. Severe contrast reaction emergencies: High-fidelity simulation training for radiology residents and technologists in a children’s hospital. Acad Radiol 2010; 17:934-940.
• Tubbs RJ, Murphy B, Mainiero MB, et al. High-fidelity medical simulation as an assessment tool for radiology residents’ acute contrast reaction management skills. J Am Coll Radiol 2009; 6:582-587.