Adapting an Objective Structured Clinical Examination (OSCE) on Conducting Difficult Conversations Between Nephrology Fellows and Patients to a Virtual Platform: A Research Letter.

Background: We previously described a nephrology-specific "Breaking Bad News" Objective Structured Clinical Examination (OSCE) assessing nephrology fellow communication and counseling skills in 3 scenarios: kidney replacement therapy (KRT) in kidney failure, urgent KRT in acute kidney injury (AKI), and kidney biopsy (KBx). Objective: The main objectives of this study is to adapt the OSCE to a virtual platform, simulating nephrology patient telemedicine encounters involving difficult conversations, and to assess fellow and faculty satisfaction with the virtual format. Design: Description of a formative telemedicine simulation for nephrology fellows. Setting: Fully virtual simulation conducted by 2 academic medical simulation centers. Participants: Nephrology faculty and fellows at 3 urban/suburban training programs in the eastern United States. Measurements: Description of the virtual OSCE process. Fellow and faculty satisfaction overall and for each scenario. Faculty and fellow estimates of frequency of virtual patient encounters in the past year. Methods: The OSCE consisted of 3 scenarios: KRT in kidney failure, urgent KRT in AKI, and KBx. Objective Structured Clinical Examinations were administered in May 2021. Each scenario lasted 20 minutes. The AKI scenario was audio only. Fellows telephoned a simulated patient surrogate for urgent KRT consent. Kidney failure and KBx scenarios were video encounters. Faculty observed while muted/video off. Immediately after the OSCE, fellows and faculty were anonymously surveyed regarding their satisfaction with each scenario, the OSCE overall, and their estimate of outpatient encounters and inpatient KRT counseling done virtually in the preceding year. Results: Seventeen fellows completed the OSCE at 2 centers (3 programs). Sixteen (94%) completed the survey. Almost 94% rated the OSCE as a good/very good approximation of telemedicine encounters. Those satisfied/very satisfied with each scenario are as follow: 100% for AKI, 75% for kidney failure, and 75% for KBx. Two commented that they often did urgent KRT counseling by telephone. Fellows estimated a median 20% (interquartile range: 175, 50%) of counseling for acute inpatient KRT and a median 50% (IQR: 33.75, 70%) of outpatient encounters were virtual in the prior year. Two (regarding the kidney failure and KBx scenarios) indicated they would not have counseled similar outpatients virtually. Limitations: The 15-minute interactions may be too short to allow the encounter to be completed comfortably. A small number of programs and fellows participated, and programs were located in urban/suburban areas on the east coast of the United States. Conclusions: Overall, fellows felt that the OSCE was a good approximation of virtual encounters. The OSCE is an opportunity for fellows to practice telemedicine communication skills.

Contexte: Nous avions précédemment décrit un examen clinique objectif structuré (ECOS) de type « annonce d'une mauvaise nouvelle ¼ en néphrologie afin d'évaluer les compétences en communication et consultation des résidents en néphrologie. L'ECOS comportait trois scénarios: thérapie de remplacement rénal (TRR) pour l'insuffisance rénale, TRR urgente dans les cas d'insuffisance rénale aiguë (IRA), et biopsie du rein (BxR). Objectifs: Adapter l'ECOS à une plateforme virtuelle, simuler des rencontres de télémédecine impliquant des conversations difficiles avec des patients en néphrologie, et évaluer la satisfaction des résidents en néphrologie et du corps enseignant à l'égard du format virtuel. Conception: Description d'une simulation de télémédecine pour la formation des résidents en néphrologie. Cadre: Des simulations entièrement virtuelles réalisées dans deux centers universitaires de simulation médicale. Participants: Les professeurs et les résidents en néphrologie de trois programs de formation urbains/suburbains de l'est des États-Unis. Mesures: Description du processus de l'ECOS virtuel. Satisfaction générale des résidents en néphrologie et du corps enseignant pour chacun des scénarios. Estimation, par les professeurs et les résidents, de la fréquence des rencontres virtuelles avec des patients au cours de la dernière année. Méthodologie: L'ECOS était composé de trois scénarios: TRR en insuffisance rénale; TRR urgente en contexte d'IRA et biopsie rénale. Les ECOS ont été réalisés en mai 2021. Chaque scénario durait 20 minutes. Le scénario IRA était audio uniquement; les boursiers devaient téléphoner à un patient simulé afin d'obtenir un consentement pour une TRR urgente. Les scénarios pour l'insuffisance rénale terminale et la BxR étaient sous forme de rencontres vidéo. Les professeurs observaient les scénarios en sourdine/hors vidéo. Immédiatement après l'ECOS, les résidents en néphrologie et les professeurs ont été interrogés de façon anonyme sur leur satisfaction à l'égard de chaque scénario et de l'ECOS dans son ensemble. Ils ont également été invités à estimer le nombre de consultations externes et de conseils prodigués sur la TRR à des patients hospitalisés au cours de l'année précédente. Résultats: Dix-sept résidents en néphrologie ont complété l'ECOS dans les deux centers (trois programs) et seize (94 %) ont répondu au sondage. La très grande majorité (94 %) a évalué l'ECOS comme une bonne/très bonne simulation des rencontres de télémédecine. Le taux de personnes satisfaites/très satisfaites s'établissait à 100 % pour le scénario de l'IRA, à 75 % pour celui de l'insuffisance rénale terminale et à 75 % pour celui de la BxR. Deux personnes ont dit faire régulièrement des consultations par téléphone pour la TRR urgente. Les résidents en néphrologie ont estimé que 20 %, (proportion médiane) ÉIQ= 175; 50 %, des consultations avec des patients hospitalisés et 50 %, (proportion médiane) ÉIQ = 33,75; 70 %, des consultations externes avaient été faites virtuellement au cours de l'année précédente. Pour les scénarios d'insuffisance rénale terminale et de BxR, deux personnes ont indiqué qu'elles ne feraient pas de consultations virtuelles pour ces patients. Limites: Les interactions de 15 minutes sont probablement trop courtes pour compléter confortablement la rencontre. Un faible nombre de programs et de résidents en néphrologie ont participé. Les programs évalués se situaient en zones urbaines et suburbaines de la côte est des États-Unis. Conclusion: Dans l'ensemble, les résidents en néphrologie ont estimé que l'ECOS était une bonne représentation des rencontres virtuelles. L'ECOS est une occasion pour les résidents de mettre en pratique leurs compétences en communication dans un contexte de télémédecine.

The Florida Clinical Skills Collaborative: A New Regional Consortium for the Assessment of Clinical Skills.

Discontinuation of the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) exam and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 2 Performance Evaluation (2-PE) raised questions about the ability of medical schools to ensure the clinical skills competence of graduating students. In February 2021, representatives from all Florida, United States, allopathic and osteopathic schools initiated a collaboration to address this critically important issue in the evolving landscape of medical education. A 5-point Likert scale survey of all members (n=18/20 individuals representing 10/10 institutions) reveals that initial interest in joining the collaboration was high among both individuals (mean 4.78, SD 0.43) and institutions (mean 4.69, SD 0.48). Most individuals (mean 4.78, SD 0.55) and institutions (mean 4.53, SD 0.72) are highly satisfied with their decision to join. Members most commonly cited a "desire to establish a shared assessment in place of Step 2 CS/2-PE" as their most important reason for joining. Experienced benefits of membership were ranked as the following: 1) Networking, 2) Shared resources for curriculum implementation, 3) Scholarship, and 4) Work towards a shared assessment in place of Step 2 CS/2-PE. Challenges of membership were ranked as the following: 1) Logistics such as scheduling and technology, 2) Agreement on common goals, 3) Total time commitment, and 4) Large group size. Members cited the "administration of a joint assessment pilot" as the highest priority for the coming year. Florida has successfully launched a regional consortium for the assessment of clinical skills competency with high levels of member satisfaction which may serve as a model for future regional consortia.

Simulation-based education improves military trainees' skill performance and self-confidence in tourniquet placement: A randomized controlled trial.

BACKGROUND: Tactical Combat Casualty Care (TCCC) is the standard of care for stabilization and treatment of military trauma patients. The Department of Defense has mandated that all service members receive role-based TCCC training and certification. Simulation education can increase procedural skills by providing opportunities for deliberate practice in safe, controlled environments. We developed and evaluated the effectiveness of a simulation-based TCCC training intervention to improve participants' skill performance and self-confidence in tourniquet placement. METHODS: This study was a single-blinded, randomized trial with waitlist controls. Army Reserve Officers Training Corp cadets from a single training battalion comprised the study population. After randomization and baseline assessment of all participants, group A alone received focused, simulation-based TCCC tourniquet application training. Three months later, all participants underwent repeat testing, and after crossover, the waitlist group B received the same intervention. Two months later, all cadets underwent a third/final assessment. The primary outcome was tourniquet placement proficiency assessed by total score achieved on a standardized eight-item skill checklist. A secondary outcome was self-confidence in tourniquet application skill as judged by participants' Likert scale ratings. RESULTS: Forty-three Army Reserve Officers Training Corp cadets completed the study protocol. Participants in both group A (n = 25) and group B (n = 18) demonstrated significantly higher performance from baseline to final assessment at 5 months and 2 months, respectively, following the intervention. Mean total checklist score of the entire study cohort increased significantly from 5.53 (SD = 2.00) at baseline to 7.56 (SD = 1.08) at time 3, a gain of 36.7% ( p < 0.001). Both groups rated their self-confidence in tourniquet placement significantly higher following the training. CONCLUSION: A simulation-based TCCC curriculum resulted in significant, consistent, and sustained improvement in participants' skill proficiency and self-confidence in tourniquet placement. Participants maintained these gains 2 months to 5 months after initial training. LEVEL OF EVIDENCE: Therapeutic/care management; Level II.

Assessing Nephrology Fellows' Skills in Communicating About Kidney Replacement Therapy and Kidney Biopsy: A Multicenter Clinical Simulation Study on Breaking Bad News.

RATIONALE & OBJECTIVE: Interpersonal communication skills and professionalism competencies are difficult to assess among nephrology trainees. We developed a formative "Breaking Bad News" simulation and implemented a study in which nephrology fellows were assessed with regard to their skills in providing counseling to simulated patients confronting the need for kidney replacement therapy (KRT) or kidney biopsy. STUDY DESIGN: Observational study of communication competency in the setting of preparing for KRT for kidney failure, for KRT for acute kidney injury (AKI), or for kidney biopsy. SETTING & PARTICIPANTS: 58 first- and second-year nephrology fellows assessed during 71 clinical evaluation sessions at 8 training programs who participated in an objective structured clinical examination of simulated patients in 2017 and 2018. PREDICTORS: Fellowship training year and clinical scenario. OUTCOME: Primary outcome was the composite score for the "overall rating" item on the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS), as assessed by simulated patients. Secondary outcomes were the score for EEC-GRS "overall rating" item for each scenario, score < 3 for any EEC-GRS item, Mini-Clinical Examination Exercise (Mini-CEX) score < 3 on at least 1 item (as assessed by faculty), and faculty and fellow satisfaction with simulation exercise (via a survey they completed). ANALYTICAL APPROACH: Nonparametric tests of hypothesis comparing performance by fellowship year (primary goal) and scenario. RESULTS: Composite scores for EEC-GRS overall rating item were not significantly different between fellowship years (P = 0.2). Only 4 of 71 fellow evaluations had an unsatisfactory score for the EEC-GRS overall rating item on any scenario. On Mini-CEX, 17% scored < 3 on at least 1 item in the kidney failure scenario; 37% and 53% scored < 3 on at least 1 item in the AKI and kidney biopsy scenarios, respectively. In the survey, 96% of fellows and 100% of faculty reported the learning objectives were met and rated the experience good or better in 3 survey rating questions. LIMITATIONS: Relatively brief time for interactions; limited familiarity with and training of simulated patients in use of EEC-GRS. CONCLUSIONS: The fellows scored highly on the EEC-GRS regardless of their training year, suggesting interpersonal communication competency is achieved early in training. The fellows did better with the kidney failure scenario than with the AKI and kidney biopsy scenarios. Structured simulated clinical examinations may be useful to inform curricular choices and may be a valuable assessment tool for communication and professionalism.

Twelve tips for facilitating and implementing clinical debriefing programmes.

Contemporary clinical practice places a high demand on healthcare workforces due to complexity and rapid evolution of guidelines. We need embedded workplace practices such as clinical debriefing (CD) to support everyday learning and patient care. Debriefing, defined as a 'guided reflective learning conversation', is most often undertaken in small groups following simulation-based experiences. However, emerging evidence suggests that debriefing may also enhance learning in clinical environments where facilitators need to simultaneously balance psychological safety, learning goals and emotional well-being. This twelve tips article summarises international experience collated at the recent Association for Medical Education in Europe (AMEE) debriefing symposium. These tips encompass the benefits of CD, as well as suggested approach to facilitation. Successful CD programmes are frequently team focussed, interdisciplinary, implemented in stages and use a clear structure.

A multi-institutional study using simulation to teach cardiopulmonary physical examination and diagnosis skills to physician assistant students.

PURPOSE: Research demonstrates limitations in the ability of health care trainees/practitioners, including physician assistants (PAs), to identify important cardiopulmonary examination findings and diagnose corresponding conditions. Studies also show that simulation-based training leads to improved performance and that these skills can transfer to real patients. This study evaluated the effectiveness of a newly developed curriculum incorporating simulation with deliberate practice for teaching cardiopulmonary physical examination/bedside diagnosis skills in the PA population. METHODS: This multi-institutional study used a pretest/posttest design. Participants, PA students from 4 different programs, received a standardized curriculum including instructor-led activities interspersed among small-group/independent self-study time. Didactic sessions and independent study featured practice with the "Harvey" simulator and use of specially developed computer-based multimedia tutorials. Preintervention: participants completed demographic questionnaires, rated self-confidence, and underwent baseline evaluation of knowledge and cardiopulmonary physical examination skills. Students logged self-study time using various learning resources. Postintervention: students again rated self-confidence and underwent repeat cognitive/performance testing using equivalent written/simulator-based assessments. RESULTS: Physician assistant students (N = 56) demonstrated significant gains in knowledge, cardiac examination technique, recognition of total cardiac findings, identification of key auscultatory findings (extra heart sounds, systolic/diastolic murmurs), and the ability to make correct diagnoses. Learner self-confidence also improved significantly. CONCLUSIONS: This study demonstrated the effectiveness of a simulation-based curriculum for teaching essential physical examination/bedside diagnosis skills to PA students. Its results reinforce those of similar/previous research, which suggest that simulation-based training is most effective under certain educational conditions. Future research will include subgroup analyses/correlation of other variables to explore best features/uses of simulation technology for training PAs.

What is evidence? Reflections on the AMEE symposium, Vienna, August 2011.

In this article, we present a summary of the discussion from the symposium on 'what is evidence', which took place at the AMEE conference in 2011. A panel of five academics and clinicians, plus the chair, considered the nature of evidence, in particular in relation to the 'evidence' in the best evidence medical education reviews. Evidence has multiple meanings depending on context and use, and this reflects the complex and often chaotic world in which we work and research.

A critical review of simulation-based medical education research: 2003-2009.

OBJECTIVES: This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit. METHODS: This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969-2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003-2009. RESULTS: The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record. CONCLUSIONS: Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts.

Development and validation of a cardiac findings checklist for use with simulator-based assessments of cardiac physical examination competence.

INTRODUCTION: Objective outcome measures for use with simulator-based assessments of cardiac physical examination competence are lacking. The current study describes the development and validation of an approach to scoring performance using a cardiac findings checklist. METHODS: A cardiac findings checklist was developed and implemented for use with a simulator-based assessment of cardiac physical examination competence at a Canadian national specialty examination in internal medicine. Candidate performance as measured using the checklist was compared with global ratings of clinical performance on the cardiac patient simulator and with overall examination performance. RESULTS: Interrater reliability for scoring the checklist ranged from 0.95 for scoring correct findings to 0.72 for scoring incorrect findings. A summary checklist score had a Pearson correlation of 0.60 with overall candidate performance on the simulator-based station. CONCLUSION: Use of a cardiac findings checklist provides one objective measure of cardiac physical examination competence that may be used with simulator-based assessments.

Simulation in health care education.

During the past 15 years there has been widespread adoption of simulation in health care education as a method to train and assess learners. Multiple factors have contributed to this movement, including reduced patient availability, limited faculty teaching time, technological advances in diagnosis and treatment that require a new skills set, greater attention to patient safety with the need to reduce medical errors, and a focus on outcomes-based education. In this discussion, simulation refers broadly to any device or set of conditions that attempts to present the patient authentically. While simulation offers many advantages over traditional methods of teaching, there are several challenges that must be addressed to ensure its effective use. This article presents the range of available simulation technologies, explores the challenges that health care educators face when using this method, provides an example of a successful program that has integrated simulation into the culture of learning at its institution, and discusses an approach to maximizing the effectiveness of simulation as a means to learning and practicing skills in a safe, interactive environment.

Assessing cardiac physical examination skills using simulation technology and real patients: a comparison study.

OBJECTIVE: High-stakes assessments of doctors' physical examination skills often employ standardised patients (SPs) who lack physical abnormalities. Simulation technology provides additional opportunities to assess these skills by mimicking physical abnormalities. The current study examined the relationship between internists' cardiac physical examination competence as assessed with simulation technology compared with that assessed with real patients (RPs). METHODS: The cardiac physical examination skills and bedside diagnostic accuracy of 28 internists were assessed during an objective structured clinical examination (OSCE). The OSCE included 3 modalities of cardiac patients: RPs with cardiac abnormalities; SPs combined with computer-based, audio-video simulations of auscultatory abnormalities, and a cardiac patient simulator (CPS) manikin. Four cardiac diagnoses and their associated cardiac findings were matched across modalities. At each station, 2 examiners independently rated a participant's physical examination technique and global clinical competence. Two investigators separately scored diagnostic accuracy. RESULTS: Inter-rater reliability between examiners for global ratings (GRs) ranged from 0.75-0.78 for the different modalities. Although there was no significant difference between participants' mean GRs for each modality, the correlations between participants' performances on each modality were low to modest: RP versus SP, r = 0.19; RP versus CPS, r = 0.22; SP versus CPS, r = 0.57 (P < 0.01). CONCLUSIONS: Methodological limitations included variability between modalities in the components contributing to examiners' GRs, a paucity of objective outcome measures and restricted case sampling. No modality provided a clear 'gold standard' for the assessment of cardiac physical examination competence. These limitations need to be addressed before determining the optimal patient modality for high-stakes assessment purposes.

Simulation technology for skills training and competency assessment in medical education.

Medical education during the past decade has witnessed a significant increase in the use of simulation technology for teaching and assessment. Contributing factors include: changes in health care delivery and academic environments that limit patient availability as educational opportunities; worldwide attention focused on the problem of medical errors and the need to improve patient safety; and the paradigm shift to outcomes-based education with its requirements for assessment and demonstration of competence. The use of simulators addresses many of these issues: they can be readily available at any time and can reproduce a wide variety of clinical conditions on demand. In lieu of the customary (and arguably unethical) system, whereby novices carry out the practice required to master various techniques--including invasive procedures--on real patients, simulation-based education allows trainees to hone their skills in a risk-free environment. Evaluators can also use simulators for reliable assessments of competence in multiple domains. For those readers less familiar with medical simulators, this article aims to provide a brief overview of these educational innovations and their uses; for decision makers in medical education, we hope to broaden awareness of the significant potential of these new technologies for improving physician training and assessment, with a resultant positive impact on patient safety and health care outcomes.

Assessing the relationship between cardiac physical examination technique and accurate bedside diagnosis during an objective structured clinical examination (OSCE).

BACKGROUND: Many standardized patient (SP) encounters employ SPs without physical findings and, thus, assess physical examination technique. The relationship between technique, accurate bedside diagnosis, and global competence in physical examination remains unclear. METHOD: Twenty-eight internists undertook a cardiac physical examination objective structured clinical examination, using three modalities: real cardiac patients (RP), "normal" SPs combined with related cardiac audio-video simulations, and a cardiology patient simulator (CPS). Two examiners assessed physical examination technique and global bedside competence. Accuracy of cardiac diagnosis was scored separately. RESULTS: The correlation coefficients between participants' physical examination technique and diagnostic accuracy were 0.39 for RP (P < .05), 0.29 for SP, and 0.30 for CPS. Patient modality impacted the relative weighting of technique and diagnostic accuracy in the determination of global competence. CONCLUSIONS: Assessments of physical examination competence should evaluate both technique and diagnostic accuracy. Patient modality affects the relative contributions of each outcome towards a global rating.

Effect of practice on standardised learning outcomes in simulation-based medical education.

OBJECTIVES: This report synthesises a subset of 31 journal articles on high-fidelity simulation-based medical education containing 32 research studies drawn from a larger qualitative review published previously. These studies were selected because they present adequate data to allow for quantitative synthesis. We hypothesised an association between hours of practice in simulation-based medical education and standardised learning outcomes measured as weighted effect sizes. METHODS: Journal articles were screened using 5 exclusion and inclusion criteria. Response data were extracted and 3 judges independently coded each study. Learning outcomes were standardised using a common metric, the average weighted effect size (AWES), due to the heterogeneity of response measures in individual studies. anova was used to evaluate AWES differences due to hours of practice on a high-fidelity medical simulator cast in 5 categories. The eta squared (eta2) statistic was used to assess the association between AWES and simulator practice hours. RESULTS: There is a strong association (eta2=0.46) between hours of practice on high-fidelity medical simulators and standardised learning outcomes. The association approximates a dose-response relationship. CONCLUSIONS: Hours of high-fidelity simulator practice have a positive, functional relationship with standardised learning outcomes in medical education. More rigorous research methods and more stringent journal editorial policies are needed to advance this field of medical education research.

Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review.

REVIEW DATE: 1969 to 2003, 34 years. BACKGROUND AND CONTEXT: Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus. OBJECTIVES: Review and synthesize existing evidence in educational science that addresses the question, 'What are the features and uses of high-fidelity medical simulations that lead to most effective learning?'. SEARCH STRATEGY: The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the 'grey literature' were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality. INCLUSION AND EXCLUSION CRITERIA: Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention. DATA EXTRACTION: Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol. DATA SYNTHESIS: Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. HEADLINE RESULTS: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following: providing feedback--51 (47%) journal articles reported that educational feedback is the most important feature of simulation-based medical education; repetitive practice--43 (39%) journal articles identified repetitive practice as a key feature involving the use of high-fidelity simulations in medical education; curriculum integration--27 (25%) journal articles cited integration of simulation-based exercises into the standard medical school or postgraduate educational curriculum as an essential feature of their effective use; range of difficulty level--15 (14%) journal articles address the importance of the range of task difficulty level as an important variable in simulation-based medical education; multiple learning strategies--11 (10%) journal articles identified the adaptability of high-fidelity simulations to multiple learning strategies as an important factor in their educational effectiveness; capture clinical variation--11 (10%) journal articles cited simulators that capture a wide variety of clinical conditions as more useful than those with a narrow range; controlled environment--10 (9%) journal articles emphasized the importance of using high-fidelity simulations in a controlled environment where learners can make, detect and correct errors without adverse consequences; individualized learning--10 (9%) journal articles highlighted the importance of having reproducible, standardized educational experiences where learners are active participants, not passive bystanders; defined outcomes--seven (6%) journal articles cited the importance of having clearly stated goals with tangible outcome measures that will more likely lead to learners mastering skills; simulator validity--four (3%) journal articles provided evidence for the direct correlation of simulation validity with effective learning. CONCLUSIONS: While research in this field needs improvement in terms of rigor and quality, high-fidelity medical simulations are educationally effective and simulation-based education complements medical education in patient care settings.

Effective use of simulations for the teaching and acquisition of veterinary professional and clinical skills.

Simulation technology will feature prominently in this exciting, yet challenging, time for veterinary medicine. The profession is evolving to keep pace with rapid changes in clinical practice, scientific discovery, and educational strategy, while ensuring that it follows the public mandate to produce competent veterinarians. Among the challenges to meeting this educational goal are limitations-due to important issues such as animal welfare-on the availability of real patients for training. Drawing chiefly on the experience in human medicine, this article explores the use of simulations in veterinary medical education to provide safe and ethical alternative opportunities for learners to practice essential clinical and professional skills.