Simulation-based education in ultrasound - diagnostic and interventional abdominal focus. / Simulationsbasierte Ausbildung im Ultraschall ­ Fokus auf der diagnostischen und interventionellen Abdomen-Sonografie.

Simulation-based training (SBT) is increasingly acknowledged worldwide and has become a popular tool for ultrasound education. Ultrasound simulation involves the use of technology and software to create a virtual training setting. Simulation-based training allows healthcare professionals to learn, practice, and improve their ultrasound imaging skills in a safe learning-based environment. SBT can provide a realistic and focused learning experience that creates a deep and immersive understanding of the complexity of ultrasound, including enhancing knowledge and confidence in specific areas of interest. Abdominal ultrasound simulation is a tool to increase patient safety and can be a cost-efficient training method. In this paper, we provide an overview of various types of abdominal ultrasound simulators, and the benefits, and challenges of SBT. We also provide examples of how to develop SBT programs and learning strategies including mastery learning. In conclusion, the growing demand for medical imaging increases the need for healthcare professionals to start using ultrasound simulators in order to keep up with the rising standards.

Generating a Prioritized List of Operative Procedures for Simulation-based Assessment of General Surgery Trainees Through Consensus.

OBJECTIVE: To develop appropriate content for high-stakes simulation-based assessments of operative competence in general surgery training through consensus. BACKGROUND: Valid methods of summative operative competence assessment are required by competency-based training programs in surgery. METHOD: An online Delphi consensus study was conducted. Procedures were derived from the competency expectations outlined by the Joint Committee on Surgical Training Curriculum 2021, and subsequent brainstorming. Procedures were rated according to their perceived importance, perceived procedural risk, how frequently they are performed, and simualtion feasibility by a purposive sample of 30 surgical trainers and a 5-person steering group. A modified Copenhagen Academy for Medical Education and Simulation Needs Assessment Formula was applied to the generated data to produce ranked procedural lists, which were returned to participants for re-prioritization. RESULTS: Prioritized lists were generated for simulation-based operative competence assessments at 2 key stages of training; the end of 'phase 2' prior to the development of a sub-specialty interest, and the end of 'phase 3', that is, end-of-training certification. A total of 21 and 16 procedures were deemed suitable for assessments at each of these stages, respectively. CONCLUSIONS: This study describes a national needs assessment approach to content generation for simulation-based assessments of operative competence in general surgery using Delphi consensus methodology. The prioritized procedural lists generated by this study can be used to further develop operative skill assessments for use in high-stakes scenarios, such as trainee progression, entrustment, and end-of-training certification, before subsequent validity testing.

A view from the top: A qualitative exploration of top-level health care leaders' perceptions on the implementation of simulation-based education in postgraduate medical education.

INTRODUCTION: Although there is substantial evidence supporting the benefits of simulation-based education (SBE), its widespread and effective implementation remains challenging. The aim of this study was to explore the perceptions of top-level health care leaders regarding SBE and the barriers and facilitators that influence its wide implementation as part of the postgraduate surgical curricula in Denmark. METHODS: We conducted semi-structured interviews with top-level health care leaders who were chosen based on their roles in ensuring high-quality patient care delivery and developing strategies to achieve the goals of the entire health care system. The interview transcripts were translated into English, and a thematic approach was used to code and inductively analyse the data. We used the Consolidated Framework for Implementation Research to identify and understand the determinants to a successful implementation of SBE. RESULTS: We interviewed 13 participants from different political and administrative levels. We found that the participants had limited knowledge about SBE, which highlighted a disconnection between these leaders and the educational environment. This was further compounded by a lack of effective communication and inadequate information dissemination between simulation centres and higher-level organisations. While participants recognised the benefits of SBE for doctors in training, they expressed concerns about the implementation given the already strained health care system and limited resources. The need for evidence, particularly in the context of patient safety, was emphasised to facilitate SBE implementation. Although participants supported the implementation of SBE, it was unclear who should initiate action. DISCUSSION: This study highlighted the perspectives of top-level health care leaders regarding SBE and identified the determinant factors for a successful implementation. Effective communication channels are crucial to enhance collaborations and reduce the disconnection between the different health care organisational levels. Strategic implementation processes, including the roles and responsibilities, should be defined and established. These will inform decisions regarding the implementation strategies to effectively integrate SBE into the residency training curricula.

Using a novel virtual-reality simulator to assess performance in lumbar puncture: a validation study.

BACKGROUND: A lumbar puncture procedure's success depends on a competent physician minimizing the risk of failing to get a sample and avoiding complications such as post-dural headache. A new virtual-reality simulator might be helpful in deciding when a physician is competent to perform lumbar puncture. We aimed to investigate validity evidence for a simulator-based test in lumbar puncture and establish a pass/fail standard to allow a mastery learning training program. METHODS: Validity evidence was investigated using Messick's framework by including participants who were novices, intermediates, or experienced in lumbar puncture. Each participant performed two lumbar puncture procedures on the simulator, and fifty-nine predefined simulator metrics were automatically recorded. Cronbach's alpha was used to explore internal consistency reliability. Intergroup comparisons were made using independent sample t-tests with Tukey's correction for multiple comparisons. The learning effect was explored using paired sample t-test analysis, and a pass/fail standard was established using the contrasting groups' method. RESULTS: 73 novices, 18 intermediates, and 19 physicians performed the test resulting in a total of 220 procedures. 25 metrics (42.4%) had good discriminatory ability, and the reliability of these metrics was good, Cronbach's α = 0.81. The experienced physicians were significantly better than the novices (18.3 vs. 13.3, p < 0.001), and the pass/fail standard was established at 16 points. This standard resulted in 22 (30.1%) novices passing (i.e., false positives) and 5 (26.3%) physicians failing (i.e., false negatives). CONCLUSION: This study provides validity evidence for a simulator-based test of lumbar puncture competence. The test can help ensure basic competence at the end of a simulation-based training program for trainees, i.e., a mastery learning training program.

The use of simulation in medical ultrasound: Current perspectives on applications and practical implementation (WFUMB state-of-the-art paper).

Simulation has been shown to improve clinical learning outcomes, speed up the learning process, and improve trainee confidence, while taking the pressure off initial face-to-face patient clinical areas. The second part of The World Federation for Ultrasound in Medicine and Biology state-of-the-art paper on the use of simulators provides a general approach on the practical implementation. The importance of needs assessment before developing a simulation-based training program is outlined. We describe the current practical implementation and critically analyze how simulators can be integrated into complex task scenarios to train small or large groups. A wide range of simulation equipment is available especially for those seeking interventional ultrasound training, ranging from animal tissue models, simple synthetic phantoms, to sophisticated high-fidelity simulation platforms using virtual reality. Virtual reality simulators provide feedback and thereby allow trainees to not only to practice their motor skills and hand eye coordination but also to interact with the simulator. Future developments will integrate more elements of automated assessment and artificial intelligence, thereby enabling enhanced realistic training experience and improving skill transfer into clinical practice.

Facilitators and Barriers to Implementation of Simulation Based Education in Vascular Surgery in Europe.

OBJECTIVE: This study explored the status and availability of simulation based education (SBE) for learning vascular surgical procedures identified in the 2019 General Needs Assessment in vascular surgery in Europe (GNA-2019) and identified facilitators and barriers to SBE implementation in vascular surgery. METHODS: A three round iterative survey was distributed via the European Society for Vascular Surgery and the Union Européenne des Médecins Spécialistes. Members from leading committees and organisations within the European vascular surgical community were invited to participate as key opinion leaders (KOLs). Three online survey rounds explored demographics, SBE availability, and facilitators and barriers to SBE implementation. RESULTS: Overall, 147 KOLs (target population 338) accepted invitation to round 1, representing 30 European countries. The dropout rates for rounds 2 and 3 were 29% and 40%, respectively. Most respondents (88%) were senior, consultant level or higher. No mandatory SBE training was required in their department before training on patients, according to 84% of the KOLs. There was high consensus on the need for structured SBE (87%) and mandatory SBE (81%). SBE is available for the top three prioritised procedures in GNA-2019 (basic open skills, basic endovascular skills, and vascular imaging interpretation) in 24, 23, and 20 of the 30 represented European countries, respectively. The highest ranking facilitators were structured SBE programmes, availability of simulation equipment locally and regionally, good quality simulators, and having a dedicated person running the SBE. The highest ranked barriers were lack of structured SBE curriculum, equipment costs, lack of SBE culture, no or limited dedicated time for faculty to teach in SBE, and clinical work overload. CONCLUSION: Based largely on the opinions of KOLs in vascular surgery in Europe, this study revealed that SBE is needed in vascular surgery training and that systematic and structured programmes are required to ensure successful implementation.

Assessment of Technical Competence in Distal Radius Fracture Fixation by a Volar Locking Plate: A Global Delphi Consensus Study.

PURPOSE: Volar locking plate fixation of distal radius fractures is a common orthopedic procedure and should be mastered by graduating orthopedic residents. Surgical education is transitioning from a traditional time-based approach to competency-based medical education. Valid and objective assessment is essential for successful transition. The purpose of this study was to develop a comprehensive, procedure-specific assessment tool to evaluate technical competence in volar locking plate osteosynthesis of a distal radius fracture. METHODS: International orthopedic/trauma experts involved in resident education participated as panelists in a four-round online Delphi process to reach consensus on the content of the assessment tool. Round 1 was an item-generating round, in which the panelists identified potential assessment parameters. In round 2, the panelists rated the importance of each suggested assessment parameter and reached consensus on which to include in the assessment tool. Round 3 yielded specific assessment score intervals for specific bone and fracture models and is not reported in this study. In round 4, the panelists assigned weights to the assessment parameters on a 1-10 scale to determine how each parameter should have an impact on the overall results. RESULTS: Eighty-seven surgeons, representing 42 countries, participated in the study. Round 1 resulted in 45 assessment parameters, grouped into five procedural steps. After round 2, the number of parameters was reduced to 39. After the final round, an additional parameter was removed and weights were assigned to the remaining parameters. CONCLUSIONS: Using a systematic methodology, a preliminary assessment tool to evaluate technical competence in distal radius fracture fixation was developed. A consensus of international experts supports the content validity of the assessment tool. CLINICAL RELEVANCE: This assessment tool represents the first step in the evidence-based assessment essential for competency-based medical education. Before implementation, further studies exploring validity of variations of the assessment tool in different educational contexts are required.

Exploring training needs of newly graduated medical doctors to inform the undergraduate simulation-based curriculum: a national Delphi consensus study.

PURPOSE: Mastering technical procedures is a key component in succeeding as a newly graduated medical doctor and is of critical importance to ensure patient safety. The efficacy of simulation-based education has been demonstrated but medical schools have different requirements for undergraduate curricula. We aimed to identify and prioritize the technical procedures needed by newly graduated medical doctors. METHODS: We conducted a national needs assessment survey using the Delphi technique to gather consensus from key opinion leaders in the field. In the first round, a brainstorm was conducted to identify all potential technical procedures. In the second round, respondents rated the need for simulation-based training of each procedure using the Copenhagen Academy for Medical Education and Simulation Needs Assessment Formula (CAMES-NAF). The third round was a final elimination and prioritization of the procedures. RESULTS: In total, 107 experts from 21 specialties answered the first round: 123 unique technical procedures were suggested. Response rates were 58% and 64% in the second and the third round, respectively. In the third round, 104 procedures were eliminated based on the consensus criterion, and the remaining 19 procedures were included and prioritized. The top five procedures were: (i) insert peripheral intravenous catheter, (ii) put on personal protection equipment, (iii) perform basic airway maneuvers, (iv) perform basic life support, and (v) perform radial artery puncture. CONCLUSION: Based on the Delphi process a final list of 19 technical procedures reached expert consensus to be included in the undergraduate curriculum for simulation-based education.

Consensus on technical procedures for simulation-based training in thoracic surgery: an international needs assessment.

OBJECTIVES: To identify and prioritize technical procedures for simulation-based training to be integrated into the thoracic surgical curriculum. METHODS: A 3-round Delphi survey was conducted from February 2022 to June 2022 among 34 key opinion leaders in thoracic surgery from 14 countries worldwide. The 1st round was a brainstorming phase to identify technical procedures that a newly qualified thoracic surgeon should be able to perform. All the suggested procedures were categorized, qualitatively analysed and sent to the 2nd round. The second round investigated: the frequency of the identified procedure at each institution, the number of thoracic surgeons that should be able to perform these procedures, the degree of risk to the patient if the procedure is performed by a non-competent thoracic surgeon and the feasibility of simulation-based education. In the 3rd round, elimination and re-ranking of the procedures from the 2nd round were performed. RESULTS: Response rates in the 3 iterative rounds were 80% (28 out of 34), 89% (25 out of 28) and 100% (25 out of 25) in the 1st, 2nd and 3rd round, respectively. Seventeen technical procedures were included for simulation-based training in the final prioritized list. The top 5 procedures were Video-Assisted Thoracoscopic Surgery (VATS) lobectomy, VATS segmentectomy, VATS mediastinal lymph node dissection, diagnostic flexible bronchoscopy and robotic-assisted thoracic surgery port placement, robotic-assisted thoracic surgery docking and undocking. CONCLUSIONS: The prioritized list of procedures represents a consensus of key thoracic surgeons worldwide. These procedures are suitable for simulation-based training and should be integrated in the thoracic surgical curriculum.

The ultrasound use of simulators, current view, and perspectives: Requirements and technical aspects (WFUMB state of the art paper).

Simulation has been shown to improve clinical learning outcomes, speed up the learning process and improve learner confidence, whilst initially taking pressure off busy clinical lists. The World Federation for Ultrasound in Medicine and Biology (WFUMB) state of the art paper on the use of simulators in ultrasound education introduces ultrasound simulation, its advantages and challenges. It describes different simulator types, including low and high-fidelity simulators, the requirements and technical aspects of simulators, followed by the clinical applications of ultrasound simulation. The paper discusses the role of ultrasound simulation in ultrasound clinical training, referencing established literature. Requirements for successful ultrasound simulation acceptance into educational structures are explored. Despite being in its infancy, ultrasound simulation already offers a wide range of training opportunities and likely holds the key to a broader point of care ultrasound education for medical students, practicing doctors, and other health care professionals. Despite the drawbacks of simulation, there are also many advantages, which are expanding rapidly as the technology evolves.

A Bi-national Needs Assessment to Identify and Prioritise Procedures in Paediatric Surgery for Simulation-based Training.

BACKGROUND: Simulation-based education (SBE) has led to significant changes in healthcare education. However, SBE has often been based on available resources and local expertise rather than a systematic approach to curriculum development. The aim of this study was to perform a bi-national needs assessment to identify and prioritise procedures in a paediatric surgery curriculum that can be supported using SBE. METHOD: A modified 3-round Delphi technique was used to gather consensus from education leaders and trainees in paediatric surgery in Australia and Aotearoa New Zealand (ANZ). Round 1 identified all procedures a newly specialised paediatric surgeon should be able to perform. In Round 2, each procedure was explored for the need for SBE using the Copenhagen Academy for Medical Education and Simulation (CAMES) Needs-Assessment Formula (NAF). This pre-prioritised list from Round 2 was sent back to participants for final exclusion and ranking in Round 3. Results 88 participants were identified and invited. From 174 procedures identified in Round 1, 71 procedures were grouped and categorised for Round 2 using the CAMES NAF. In Round 3, 17 procedures were eliminated resulting in 54 procedures. Appendicectomy, inguinal herniotomy, and central venous access were the highest rank procedures after prioritisation in Round 3. There was a strong correlation (r = 0.99) between the NAF score and the prioritised ranking, as well as between consultants and trainees (r = 0.92 in Round 2 and 0.98 in Round 3). CONCLUSION: The prioritised list represents a consensus document decided upon by education leaders and stakeholders in paediatric surgery. These procedures should be an integral part of the SBE of paediatric surgeons in the region. LEVEL OF EVIDENCE: Level V.

A national needs assessment to identify technical procedures in plastic surgery for simulation-based training.

Medical simulation is not developed and integrated into plastic surgery unlike other surgical specialties despite the procedures being complex and require practice. First step in enhancing simulation in plastic surgery is to clarify the need among peers. The objective of the study was to identify and prioritize the technical procedures that should be included in a simulation-based curriculum for residency training in plastic surgery. A panel of participants with key roles in the Danish plastic surgery specialist training program was appointed. Participation was voluntary. A national need assessment study was performed using a three-round Delphi process to collect information from the participants. In round 1, participants reported all the procedures that a newly qualified specialist in plastic surgery should be able to perform. In round 2, participants replied to a survey exploring the frequency of the procedures, the number of surgeons performing the procedure, the risk or discomfort for patients treated by an inexperienced surgeon and the feasibility of training the procedure in simulation, resulting in a preliminary ranking of procedures. In round 3, participants eliminated and reprioritized the identified procedures according to importance. Thirty-five of 37 agreed to enter the expert panel. The response rate was 97%, 86% and 86% for rounds 1, 2 and 3, respectively. Twenty-nine of 136 procedures identified in round 1 reached the final prioritized list of procedures relevant for simulation training in plastic surgery.

Development of a Rubric to Evaluate Implementation Quality of Simulation-Based Courses: A Consensus Study.

INTRODUCTION: Simulation-based education is a recognized way of developing medical competencies, and there is overwhelming scientific evidence to support its efficacy. However, it is still underused, which can often be related to poor implementation process. In addition, best practices for implementation of simulation-based courses based on implementation science are not widely known nor applied. The purpose of this study was to develop a rubric, the Implementation Quality Rubric for Simulation (IQR-SIM), to evaluate the implementation quality of simulation-based courses. METHODS: A 3-round, modified Delphi process involving international simulation and implementation experts was initiated to gather and converge opinions regarding criteria for evaluating the implementation quality of simulation-based courses. Candidate items for Round 1 were developed based on the Adapted Implementation Model for Simulation. Items were revised and expanded to include descriptive anchors for evaluation in Round 2. Criterion for inclusion was 70% of respondents selecting an importance rating of 4 or 5/5. Round 3 provided refinement and final approval of items and anchors. RESULTS: Thirty-three experts from 9 countries participated. The initial rubric of 32 items was reduced to 18 items after 3 Delphi rounds, resulting in the IQR-SIM: a 3-point rating scale, with nonscored options "Don't know/can't assess" and "Not applicable," and a comments section. CONCLUSIONS: The IQR-SIM is an operational tool that can be used to evaluate the implementation quality of simulation-based courses and aid in the implementation process to identify gaps, monitor the process, and promote the achievement of desired implementation and learning outcomes.

Consensus on communication curriculum content in Danish undergraduate medical education: A Delphi study.

BACKGROUND: The acquisition of skills in patient-centered communication is a critical aspect of medical education which demands both resource-intensive instruction and longitudinal opportunities for learning. Significant variation currently exists in the content and timing of communication education. The aim of this study was to establish consensus regarding communication curriculum content for undergraduate medical education (UME) within the country of Denmark. METHODS: This study employed a Delphi process which is a widely accepted method for establishing consensus among experts and can be utilized to guide planning and decision-making in education. For this study, consensus was based on greater than 60% agreement between participants. Diverse stakeholders, representing all four universities with medical schools in Denmark, participated in an iterative three-round Delphi process which involved: (1) identifying key curricular elements for medical student education, (2) rating the importance of each item, and (3) prioritizing items relative to one another and rating each item based on the level of mastery that was expected for each skill (i.e. knowledge, performance with supervision, or performance independently). RESULTS: A national sample of 149 stakeholders participated with a 70% response rate for round 1, 81% for round 2, and 86% for round 3. The completed Delphi process yielded 56 content items which were prioritized in rank order lists within five categories: (1) establishing rapport, engaging patient perspectives and responding to needs; (2) basic communication skills and techniques; (3) phases and structure of the encounter; (4) personal characteristics and skills of the student; (5) specific challenging patient groups and context-dependent situations. DISCUSSION: Using a Delphi process, it was possible to achieve consensus regarding communication curriculum content for UME. These findings provide an important foundation for ensuring greater uniformity in UME, as well as supporting the important longitudinal goals of communication skill development across medical training.

The knowledge and skills needed to perform intestinal ultrasound for inflammatory bowel diseases-an international Delphi consensus survey.

BACKGROUND: Intestinal ultrasound (IUS) is a non-invasive modality for monitoring disease activity in inflammatory bowel diseases (IBD). IUS training currently lacks well-defined standards and international consensus on competency criteria. AIM: To achieve international consensus on what competencies should be expected from a newly certified IUS practitioner. METHODS: A three-round, iterative Delphi process was conducted among 54 IUS experts from 17 countries. Round 1 was a brainstorming phase with an open-ended question to identify the knowledge and skills that experts believe a newly certified IUS practitioner should possess. The experts' suggestions were then organised into statements by a Steering Committee. In round 2, the experts commented upon and rated the statements, which were revised accordingly. In round 3, the experts rated the revised statements. Statements meeting the pre-defined consensus criterion of at least 70% agreement were included in the final list of statements. RESULTS: In total, 858 items were suggested by the experts in the first round. Based on these suggestions, 55 statements were organised into three categories: knowledge, technical skills and interpretation skills. After the second round, 53 revised statements remained. After the final round, a total of 41 statements had achieved consensus. CONCLUSIONS: We established international, expert consensus on the knowledge and skills that should be expected from newly certified IUS practitioners. These consensus statements are the first step towards mastery learning for IUS training. Educators can utilise these statements to design training programmes and evaluate the competencies of trainees before they engage in independent practice.

A core curriculum for basic EUS skills: An international consensus using the Delphi methodology.

Background and Objectives: During recent years, the demand for EUS has increased. However, standardized training programs and assessments of clinical quality measures are lacking. We therefore aimed to establish a basic curriculum for EUS fellows that includes a prioritized list of interpretational capabilities and technical skills. Materials and Methods: International key-opinion leaders were invited to participate in a Delphi process. An electronic three-round iterative survey was performed to attain consensus on skills that 70% of the participants found either very important or essential for a newly graduated endosonographer. Results: Of 125 invited experts, 77 participated in the survey. Initially, 1,088 skills were suggested, resulting in a core curriculum containing 29 interpretational skills and 12 technical skills. The top-five interpretation skills included abilities to discern between normal anatomy and pathology, to identify the entire pancreas and ampullary region, to identify solid versus fluid-filled structures, to detect bile duct and gallstones, and to identify a pancreatic mass of 5 mm or larger. For technical skills, ability to insert the endoscope from the mouth to the second part of duodenum, to obtain FNA adequately and safely, to navigate the scope tip to follow anatomical landmark structures, to achieve endoscopic position of each of the four stations, and to perform passage of the scope past a hiatal hernia were given the highest ranking. Conclusions: After a structured Delphi process involving 77 international experts, a consensus was reached for a basic curriculum for EUS fellows to be included during training.

Developing a simulation-based training curriculum in transesophageal ultrasound with the use of the endobronchial ultrasound-endoscope.

There is an increasing need to focus on how best to train respiratory physicians to perform EUS with bronchoscope-guided fine-needle aspiration biopsy (EUS-B-FNA). At current, training is mostly performed in the clinical environment under expert supervision; however, the advent of simulation-based education now provides a low-risk setting for novice trainees to learn and practice basic endosonography skills from identifying and understanding normal anatomy as well as pathology, maneuvering of endoscope, interpretation of images, and mastering of sampling techniques. In this descriptive educational paper, we used a six-step approach as a framework to describe the development of a structured training program combining EUS-B-FNA with the already well-established certification training program in endobronchial ultrasound transbronchial needle aspiration. This comprehensive training curriculum includes a theoretical course to achieve foundational knowledge, followed by simulation-based training until mastery standards are met, and supervised clinical apprenticeship. All steps should end with an objective assessment to achieve certification. This systematic development will hopefully encourage endosonography leaders and educators to collaborate and implement an evidence-based comprehensive endosonography curriculum that aims to provide the trainee with the essential EUS-B competencies to ensure that lung cancer patients are diagnosed and staged correctly.