SimWars: A "warring tigers" competition

SimWars

You’ve seen this word on the agenda at the most recent Emergency Medicine conference that you attended. It sounded interesting... but you ended up going to a happy hour and missed out on the event. And so you are left with the burning question, what is SimWars?

I have now heard Dr. Haru Okuda (Director of VA SIMLEARN) introduce SimWars a few times at the start of competitions at conferences. He usually has a photo of two cute little kittens with great big sweet eyes juxtaposed with a photo of two warring tigers fighting each other. He uses this comedic relief to illustrate the difference between a standard simulation session and SimWars competition. 

A hilarious video that playfully shows the competitive nature of the competition can be seen in this clip for the upcoming Social Medical and Critical Care (SMACC) Conference in Sydney on March 11-13, 2013.  

The History of SimWars
Creators, Drs. Andy Godwin (EM Chair of Univ of Florida-Jacksonville), Haru Okuda and Scott Weingart (Mt. Sinai-NY and Emcrit.org) originally developed SimWars in response to an observed lack of urgency in response to simulated cases used in education. They watched their residents wait for the inevitable bomb to drop before actively managing the patient and thought perhaps they could build some healthy stress into the scenarios. 

In addition to providing an avenue for large group education at local, national and international conferences, SimWars allows a unique opportunity to observe the differences in how different training programs address similar situations. SimWars is also a way to showcase the utility of simulation training to more “sim-naïve” educators. It’s definitely an exciting introduction to those new to simulation.

SimWars presence at major meetings

SimWars were held at the recent SAEM, ACEP, International Meeting on Simulation in Healthcare (IMSH), and the Canadian Simulation Summit conferences. This allowed the demonstration of interdisciplinary teamwork and communication, which was the focus of such events as IMSH and the Canadian Simulation Summit. Dr. Lisa Jacobson (University of Florida-Jacksonville) has joined the SimWars team and coordinates much of the ground work.

Personal perspective

I have participated myself as a confederate and case writer.  Confederates, or “actors,” play an important role. We often are the source of important information, whether it be subtle exam findings or significant history, but just as in actual care environments, these details may be difficult to glean amidst obstructive/entertaining personalities or surrounding chaos. It is the confederates’ role to provide a balance between chaos and flow, helping to move the case quickly forward to adhere to the short time periods necessary for a competition. 

Case writing is also a fun challenge. We get to brainstorm all the possible ways a team may respond to the case and how to create manageable barriers for them to overcome. You don’t want the case to be too easy, nor do you want the case to be impossible. Most importantly there should be specific educational goals. Watch out for those twists!

Bottom line

Ultimately, I have found SimWars  to be an unique educational platform, which balances the entertaining and the challenging. There are plenty of opportunities to learn and educate, whether you are a judge, a sim team member, confederate, or case writer.

Join me at the next SimWars competition in Orlando, FL at the IMSH Simulation conference (Jan 26-30, 2013)!

Special thanks to Dr. Lisa Jacobson for her help and contribution to this blog write up.

New Years Resolution: More teachable moments please

“The worst thing about busy shifts is that I never learn anything.”

My junior resident and I were contemplating the many difficulties of residency, especially when working at a busy urban ED where patients are plenty, but teaching during shifts may be harder to come by. We discussed the importance of coming up with at least one learning point or clinical question during each shift, and making a point of following through and reading up on it after.  (That shift we both learned about fat emboli s/p extremity fracture.)

But even with self-initiated learning adventures, I think that it is important that faculty and senior residents take the lead and actively work to ensure that learning occurs for every resident and every medical student during every shift, throughout all years of residency. Some educators actually say that something can be taught on just about every case seen with a resident if approached correctly.

2013 New Year’s Resolution:  
Create 1 teachable moment, for every resident and every medical student, during every shift!

Wait! 
Don’t get overwhelmed with that resolution. 
It is completely do-able!

What is a teachable moment, and how to teach for that moment?  First off, a teachable moment is exactly that, A TEACHABLE MOMENT! Not hour, not lecture, not thesis statement. But, by allowing the thought of the teaching to overwhelm the teacher, we create mountains and mental barriers. How often have we felt that it was too exhausting to explain to the junior the intricacy of the discriminate zone of beta-hcgs regarding work up of ectopic pregnancies, especially with a wait time over 6 hours?

I remember one attending that I worked with who would actually write down a checklist of three items for every patient that I would present to him. This checklist was not a To-Do list, but instead was solely dedicated to three learning points that he wanted me to have for each patient that I presented to him. We all know about the checklist manifesto for getting tasked completed… why not a checklist manifesto for teaching points?

I asked a few experts via Twitter for their thoughts on teachable moments.

Lets resolve for 2013 to incorporate more time for bedside teaching, any tips on how to accomplish this?
— Nikita Joshi (@njoshi8) December 30, 2012

Dr. Mallemat (@CriticalCareNow) and Dr. Gharahbaghian (@Sonospot) mentioned that bedside ultrasound is a great opportunity to not only teach about pathology, but also anatomy!  Which means it is perfect for teaching the medical student at the beginner level, and all the way up to senior resident at expert level.  

@TheSGEM felt that ALL moments were teachable moments.  

@BobStuntz stated that the key is to limit the teaching moment to 1 pearl or point only.  Think back to when you learned about that topic. Was there a learning point or pearl that stuck out for you?  If so, focus on that point during your short discussion.

There is a caveat to all of this… don’t forget that we all are in a constant state of learning, even if we don’t appear to be so. A senior resident once told me  it was particularly difficult to learn anything during shifts because attendings were so willing to defer to her judgment. This is a great amount of responsibility, but always remember that as doctors, there is always room for more.

Lets resolve to bring more learning and teaching on! 

Happy New Year!

To debrief or not?

Learners have limited time. Residents have work hours restrictions, practicing physicians have work / life demands, and the list goes on. Time is valuable. Therefore, educational interventions must be hard-hitting, effective, and worthwhile.

We discussed previously "What is debriefing?" Debriefing is a facilitated discussion and reflection about objectives previously chosen by the educator. Dr. Ernest Wang (NorthShore Center for Simulation and Innovation) states that it's about getting learners to that “aha!” moment.

NCSI CSTAR Facilitative Debriefing Video from Ernest Wang on Vimeo.

According to Fanning and Gaba [1], deciding when to debrief is twofold:

1. Do participants lack a sense of closure? 
2. Can we derive useful insights through a discussion of the experience? 

Therefore, we debrief to give participants a conclusion to their learning experience, a manner by which to derive conclusions. We also debrief to provide insights as a group that may not be possible to derive as individuals.

Dr. Roger Greenaway is a UK PhD who specializes in training organizations on the benefits of active and experiential learning.  His website has published a list of 10 reasons on why to review (aka debrief).  These are some of the important points:

• Getting unstuck: Debriefing helps the learner to progress in the cycle of learning and development. 
• Opening new perspectives: Learners can understand complexities in medical management and realize that there is more than one right answer. 
• Developing observational awareness: We all want to become thoughtful and observant physicians able to gather subtle patient clues and condense medical information quickly. Debriefing helps to point out missed clues.

Think of debriefing as a way of accelerating knowledge acquisition and takes learners to the next level. So it is definitely hard hitting!

This is the second of several blog posts on debriefing. Future write ups will discuss the evidence behind debriefing, debriefing techniques, and where to get formal training in debriefing.

References

1. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007. Summer;2(2):115-25. PMID 19088616.
2. Thiagarajan S: Using games for debriefing. Simul Gaming 1992;23: 161–173.

Teaching internationally: More than just a language barrier

I recently traveled to San Salvador to help teach a pediatric and adult ultrasound course. The course was well received and it was wonderful traveling around San Salvador.

I wanted to share some of our experiences, and discuss some challenges to educating internationally. More importantly, I want to engage you, the readers to share some of your experiences when educating internationally as well.

The language

The first challenge and major road block was attempting to lecture in a foreign language. Although I studied Spanish for many years, I was definitely rusty. While I learned the history of the Argentinian Dirty War in school, I never mastered vocabulary sufficient to discuss the physics of ultrasound. We translated the majority of the presentations into Spanish by using the aid of colleagues who were from El Salvador and Google translator. Imagine how difficult this would be for languages that are not based on the Roman alphabet or if there were no native language speaking colleagues to assist. Even with that, there were still some funny hiccups.

Delivering presentations

Creating the presentations is half the battle. Delivering the presentation is even more daunting.

We all know that good lecturers don’t read off of their slides.  They can ad-lib, interact with the crowd, and make adjustments as necessary.  This becomes more difficult in another language.  No one wants to deliver a bad presentation simply because it is in another language.  Or worse, give a bizarre answer to a question because of translation issues.  I definitely practiced my presentations more than I would usually.  The butterflies in my belly before presenting were palpable!

AV equipment

A major challenge was ensuring that the AV equipment worked properly.  Although traveling with 5 other EM physicians in my group, none of us remembered to bring a dongle to connect our laptops with the AV equipment in the hospital.  Luckily, we were able to find a store and could buy the necessary missing equipment.  However, you may not always be so lucky when traveling internationally to be near an urban center.  It is important to be organized to try to limit as much AV malfunction as possible.  Remain flexible and know that there may be some level of malfunction and be prepared to address it.  Having a backup plan such as hard copies of the lecture could be life (and reputation) saving.

Ultrasound equipment

Finally there is the challenge of traveling with the portable ultrasounds internationally.

• Customs doesn’t always know what a portable ultrasound machine is. Plus, it takes coordination to organize carry-on luggage as the ultrasound, check in your suitcase, and manage your souvenirs-- all without incurring additional travels charges.
• Don’t forget how heavy the ultrasound machines can be on your back!  
• Ultrasound machines are expensive. We always knew their locations to avoid losing them.

Ethical question
There was the ethical dilemma of using our high tech portable ultrasound donated by companies for international education versus using the machines that the hospitals already had.  Our equipment was definitely more advanced, but what purpose does it serve to not teach familiarity to what is available?  This is a thought that definitely can be pondered upon and argued over.

Lessons I learned:

•  Practice, practice, and practice again when delivering a presentation that is not in your primary language
•   Think about AV equipment - consider backups
•   Ultrasound machines are heavy and costly
•   Always consider sustainability

Please share any lessons you may have learned while traveling and educating internationally!

The secret to patient presentations

So there’s a patient, and umm...  they are in the hallway, they came to the ED today for breathing problems, I mean dyspnea.  They also don’t speak any English.  So, uh the respiratory rate is normal, and they had a blood clot, er... I mean PE, in the past, but not on coumadin anymore.  Shoot, I forgot to tell you my exam...they had pitting edema for 3 months.  By the way, the labs came back on that other anemic patient in the other hallway, and they are really anemic...

Sounds familiar? Perhaps a medical student or intern-level presentation of a patient in the ED?  Imagine working in a hectic ED while listening to this chaotic presentation. 

What's the secret to presenting patients?

We, as attendings or senior residents, often assume that increasing knowledge will lead to improved presentations, and so focus on broadening their medical knowledge. That's only part of the solution.

What's the other part? Polishing the trainee's public speaking skills.  This is just like recommending to a lecturer that to improve their lectures, they should develop public speaking skills. In this case, the lecturer (trainee) is lecturing to an audience of one (attending).

Think of presentations as mini-impromptu speeches.  

Important qualities in public speaking:

• Lack of fillers (um, so, uh, really, like)
• Knowledge of content
• Brevity
• Organized structure
• Eye contact
• Subject matter of pertinence to the audience
• Practice (go over the presentation in your head once before giving it)

As a senior resident or attending taking patient presentations, imagine a presentation that is succinct (less than 1-2 minutes), where the trainee avoids filler words, with an organized history, physical, assessment, and plan.  Imagine a presentation that does not deviate but remains true to the topic and tells a coherent story.  This type of presentation would almost be like a gentle relief in an over-stimulated ED environment.

Just as how you probably would not interrupt a good public speaker in the middle of his/her speech,  you should hold your questions until the end of their presentation. Remember this, and try to allow the trainees to finish speaking.  It may help them to keep their train of thought and structure.

For the senior resident or attending:

• I challenge you to consider these aspects of public speaking the next time you listen to a patient presentation from a student or resident. See if you can make recommendations to improve his/her presentation style as well as the content.

For the trainee:

• Work on being a better public speaker. 
• As a side note, I was a part of Toastmasters International which is a nonprofit public speaking organization while in college.  Although I am no longer with the organization, I credit them with significantly improving my confidence and public speaking skills in both prepared and impromptu styles. Plus it was a lot of fun!  This is definitely something to consider if you are looking for a way to improve your public speaking skills.

What is debriefing in simulation education?

Debriefing at the Univ of New England

Medical education high-fidelity simulation allows for deliberate practice in a safe environment. We are able to miss the intubation repeatedly or botch up the management of aspirin overdose without the demise of the patient.  At the end of each session, we gather in a pow wow and debrief….

I have been involved with debriefings, and often wonder what residents are thinking:

• Do they understand what debriefing means? 
• Do they think this is the time where they are scolded for mistakes? 
• Do they think it is a valuable part of the simulation?

What does debriefing even mean? 

Debriefing is a broad topic, and definitions vary depending on the field of reference such as medical education versus aviation.  My goal is to provide an overview and only discuss what is debriefing within the simulation medical education context. 

According to Fanning and Gaba [1], debriefing is “facilitated or guided reflection in the cycle of experiential learning.”  Harvard’s Center for Medical Simulation describes debriefing as a conversation among participants with the ultimate goal to improve performance in real situations. [2] It is a process by which to identify and address gaps in knowledge and skills. [3] 

Debriefing (post-experience analysis) is thought to be one of the most important features of simulation based medical education. Simulation can lead to an experience that is emotional and thought provoking - aka experiential learning. (Think of how you feel when you poorly execute the resuscitation of the manikin in a simulation session.)  Debriefing plays a role in the reflection and analysis of that experiential learning.

The following elements are usually involved in debriefing: 

• Facilitator
• Participants to debrief
• Experience
• Impact of the experience
• Recollection
• Report
• Application

The Participants go through the simulation case (Experience) and develop an Impact from the experience.  During the debriefing they Recollect the impact, and Report upon it.  Although reflection often happens regardless, debriefing allows the Facilitator to organize the reflection in a productive manner. 

Think of the last resuscitation that you felt was botched up.  You probably reflected on it alone, hopefully not in the local bar.  Your reflections may have been scattered and perhaps included unproductive self-criticisms that didn’t aid learning.  Compare that to your last simulation session where there was a useful structured reflection with a facilitator, learning points were discussed, and hopefully lessons were retained for a longer period.

Ultimately the goal of debriefing is to engage in a conversation where learning happens. It is an open format for discussion of the events that occurred, how we felt about it, and understanding the thought processes.  It allows for identifying areas where perhaps knowledge or skill was missing so that it can be corrected in the future.  So maybe debriefing is a little touchy-feely, but what’s wrong with a little human contact?!

The purpose of this post was to discuss what is debriefing; future posts will discuss why we debrief.  I would love your thoughts on this subject.  Please feel free to discuss!

References

1. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007. Summer;2(2):115-25. PMID 19088616.
2. "DebriefingAssessment for Simulation in Healthcare (DASH)." DASH. Center for Medical Simulation, 2009. Web. 03 Nov. 2012.
3. Raemer D, Anderson M, Cheng A, Fanning R, Nadkarni V, Savoldelli G. Research regarding debriefing as part of the learning process. Simul Healthc. 2011 Aug 6; Supple:S52-7. PMID 21817862.

Thanks to Dr. Stella Yiu and Dr. Javier Benitez for letting us know about Dr. Hart's and Dr. Ernest Wang's videos on Debriefing, respectively:

High Fidelity Cased Based Simulation Debriefing from Academic Emergency Medicine on Vimeo.

Facilitative Debriefing Techniques for Simulation-based Learning from Academic Emergency Medicine on Vimeo.

New blog section on Medical Education by Dr. Nikita Joshi

Introduction of a new section on Medical Education

Sir William Osler, renowned physician and believer in bedside medical education, once stated:

“I desire no other epitaph…than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.”

And with this quotation I would like to introduce a new segment to Academic Life in Emergency Medicine.  One of the most important job descriptions we have as physicians is to be a clinical instructor… while simultaneously running cardiac arrest codes, managing agitated altered mental status patients, and avoiding documentation errors.

It is a tremendous task, especially considering the multitasking, organizational, and time management skills that are already demanded of us.  However, the ED is the perfect setting to provide medical education at levels including medical students, residents, and junior faculty as well.

With this blog, I hope to discuss issues such as:

• Bedside teaching tips
• Relevant medical educational theories
• Small and large group lecturing tips
• Effective use of technology, such as iPads in providing medical education.  

This section will ideally provide a forum for discussion as a place to share ideas, concepts, and successes from other readers. Ultimately, I hope to excite passion for medical education and to provide practical ideas for teaching.

Additional reading:

• "Oslerisms" from Life in the Fast Lane medical education blog
• "William Osler - Biography" from Medical Archives at Johns Hopkins

Welcome new blog team member: Dr. Nikita Joshi

Welcome our newest team member on the blog with a specific focus on teaching about Medical Education, Dr. Nikita Joshi!

She is a graduating EM resident, pursuing a career in academics. "My goal with this blog is to share ideas, thoughts, and experiences about teaching. Teaching is after all one of our most sacred and treasured skills as clinicians. I hope to ignite the same passion I have with the readers and to engage in insightful dialogue."