Workshop Leaders: Sabrina Butteris , MD & Michael Pitt, MD Co-Presenters: Amer Al-Nimr, MD Jacquelyn Kuzminski, MD Anagha Loharikar, MD Molly Shane, MD Chuck Schubert, MD Nicole St. Clair, MD Sarah Webber, MD
Disclosure Slide
We have no financial relationships relevant to this workshop to disclose.
Questions/Wrap Up (25 min)
Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)
Break (10 min) Return in Small Groups
Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief
Break (10 min)
How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script
SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot
Welcome/Introductions (10 min)
Background • Supply is catching up to demand o Over half of pediatric residency programs offer GH electives
• Proper preparation is key
• Difficulty in handling the emotional obstacles encountered
abroad is frequently discussed in post-trip debriefing • Active preparatory curricula allowing residents to experience
and debrief potential emotional challenges encountered abroad are lacking
+
Could we use medical simulation to prepare global health residents for common emotional challenges encountered abroad, rather than just medical preparation?
Simulation Use for Global Away Rotations (SUGAR) • PRIMARY GOAL: Develop and
evaluate a standardized simulation curriculum to prepare residents to better deal with the common emotional challenges encountered on global health rotations
• SECONDARY GOALS: • Reinforce medical knowledge of
less familiar diseases and management
• Experience the challenges of working with limited resources
• Encourage problem-solving skills • Appreciate challenges of
providing care across cultures • Foster humility
Common emotions encountered on GH electives
• Frustration at slower pace, less urgency, lack of resources
• Difficulty understanding apparent differences in dealing with death and dying
• Battling a sense of superiority when it comes to medical management
• Fear or uncertainty with how to manage new diseases
Frustration
“I know what I would do back home to manage this disease, but I don’t have the ability to
do it here.”
Ex: DKA without an insulin drip
Adaptability
“I was able to overcome obstacles encountered in a
resource-limited environment and ultimately help this
patient.”
Floundering
“I don’t know what to do with the disease or where to find information that could help
me.”
Ex: Lymphocytic Interstitial Pneumonitis
Awareness of Resources
“I was able to utilize available resources to learn how to
manage a disease I had little experience with and ultimately
helped the patient.”
Turning an F into an A
Futility
“Why does everyone seem so complacent with death here? Am I the only one who cares?
What will happen to this patient if we ‘save’ her.”
Ex: Prolonged resuscitation of a neonate without access to a
ventilator
Acknowledgement
“Sometimes death is unavoidable. A patient dying is difficult for everyone; how this is expressed may be different than what I am accustomed to
but this doesn’t mean my hosts are not affected by it.”
Turning an F into an A
Failure
“I thought I knew how to make this patient better, but I am
making them worse. What is different about this patient in
this environment?”
Ex: Management of shock in severe acute malnutrition
Adjustment/ Humility
“I learned that having false assumptions that patients will always be physiologically the same as those I am used to,
can at times be harmful.”
2 Page Case Outline 1 Page Debriefing Script
&
SUGAR Study: Phase 1 • Seven institutions participated (IRB obtained at all)
• Program size ranged from 34-108 pediatric residents • 12-51% residents participating in GH • 5/7 programs with formal GH track
• Evaluation (anonymous and optional) • Residents
• How useful in preparation for GH elective • Emotions encounter during the case (if any) • Planned changes as a result of simulation (if any)
• Facilitators • How useful? • Emotions elicited (if any)
Results
95 residents invited across
seven sites
51 residents came to
session(s) (54%)
160 resident evaluations completed
75% from participants
25% from observers
16 facilitators across seven
sites
52 facilitator evaluations completed
1 Year | Seven Institutions
Resident and Facilitator Perception of the Usefulness of the Simulation Session
Category n (evaluations) Mean(SD)
Overall Resident 160 4.5 (0.8) Facilitator 52 4.9 (0.4)
Resident role Participant 128 4.5 (0.8) Observer 32 4.3 (1)
Resident level of training
PGY1 59 4.4 (0.7) PGY2 49 4.4 (1.1) PGY3 43 4.6 (0.5)
PGY4+ 9 5 (0)
Resident specialty
Pediatrics 134 4.5 (0.9) Medicine-Pediatrics 10 4.4 (0.8)
Family Medicine 12 4.7 (0.5) Fellow 4 5 (0)
Resident response by site
Site 1 25 4.8 (0.4) Site 2 6 4.8 (0.4) Site 3 2 5 (0) Site 4 11 4.8 (0.6) Site 5 37 3.8 (1.1) Site 6 20 4.8 (0.4) Site 7 59 4.6 (0.7)
Facilitator response by site
Site 1 7 4.7 (0.5) Site 2 6 4.7 (0.5) Site 3 3 4.7 (0.6) Site 4 11 4.9 (0.3) Site 5 4 4.8 (0.5) Site 6 10 5 (0) Site 7 11 4.9 (0.3)
Representative Quotes
“Frustration with lack of resources and the amount of time it took to do
simple tests.”
“Sadness that the child would return to a life of poverty and possibly dozens of recurrences.”
“Feeling helpless. Not knowing how to respond emotionally.” “Confusion at recognizing a
problem but being unsure of its treatment without labs, etc.”
ACTIVATED
REFLECTIVE
POSITIVE
NEGATIVE
Frustration (74/156; 47%) Anxiety/Worry (20; 13%) Uncomfortable (11; 7%) Fear (8; 5%) Stress/Overwhelmed (6; 4%)
Excited (3; 2%)
Incompetent/Ill-Prepared (9; 6%) Sadness (22; 14%) Helpless (20; 13%) Futility (7; 5%) Confusion (15; 10%) Guilt (2; 1%)
Satisfied (13; 8%) Confident (5; 3%) Curious (2; 1%)
No Emotion (3; 2%)
Conclusions • The novel SUGAR curriculum was able to be incorporated in
varied programs with reproducible success and minimal training
• Residents and facilitators overwhelmingly rated the
curriculum as useful • SUGAR was able to elicit emotions with over 98% of
residents’ comments indicated they had an emotional response and this was the most common theme of debriefing
• Residents indicated planned change to their preparation as
the result of this curriculum
Resident Response - Are there any changes to your global health rotation pre-trip preparation that you anticipate making as a result of this simulation session?
(n=137 written comments)
Change in Pre-Trip Preparation
Number of Comments with Theme
(%)
Representative Quote
Expand/review medical knowledge 76 (55) “Familiarize myself with common illnesses and
complications in limited resource settings.” Obtain and take specific resources with me 26 (19) “Bring WHO Hospital Care for Children* handbook
along with me.”
Learn about local resources 22 (16) “Taking more time to try and understand available resources and treatment limitations before scenarios arise.”
Cultural/language preparation 12 (9) “Knowing to talk with locals about end of life
culturally.” Emotional and mental preparation 9 (7) “Prepare to deal with difficult conversations with
parents.”
Learning about roles and expectations 7 (5) “Think about expectations and role.”
Practice/gain clinical skills 6 (4) "Practice Neonatal Resuscitation Program (NRP).”
No changes 6 (4) “Not pre-trip [changes], but it makes me more cognizant of asking about resources once arriving.”
*Pocket Book of Hospital care for children. WHO Press. 2013.
Limitations • Variations in numbers of cases completed at each
institutions make comparative statistics impossible • Did not assess whether residents’ anticipated
changes in preparation translate to actual changes in preparation before their trip (YET)
Next Steps • Publish and disseminate curriculum • New cases • Feedback on return from GH rotation
Acknowledgements
Cindy Howard, MD Chandy John, MD, MS Ann Campagna, MD Tina Slusher, MD
Sabrina Butteris, MD Laura Houser, MD Scott Hagen, MD
Walter Eppich, MD, Med Molly Shane, MD Anagha Loharikar, MD
Nicole St. Clair, MD Jacquelyn Kuzminksi, MD
Phillip Fischer, MD Jane Rosenman, MD
Amer Al-Nimr, MD
Chuck Schubert, MD Stephen Warrick, MD
Questions/Wrap Up (25 min)
Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)
Break (10 min) Return in Small Groups
Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief
Break (10 min)
How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script
SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot
Welcome/Introductions (10 min)
INSERT BINDER SCREENSHOTS ON NEXT SLIDES TABLE OF CONTENTS
INCOMPLETE
INSERT BINDER SCREENSHOTS ON NEXT SLIDES CASE EXAMPLE
INCOMPLETE
INSERT BINDER SCREENSHOTS ON NEXT SLIDES DEBRIEFING SCRIPT
INCOMPLETE
Questions/Wrap Up (25 min)
Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)
Break (10 min) Return in Small Groups
Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief
Break (10 min)
How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script
SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot
Welcome/Introductions (10 min)
Questions/Wrap Up (25 min)
Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)
Break (10 min) Return in Small Groups
Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief
Break (10 min)
How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script
SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot
Welcome/Introductions (10 min)
Some Tips for Observing • Follow along in the case (Case 1A)
• Pay particular attention to the introduction of obstacles and the use of silence
• Ask yourself what you would do in the resident’s position as well as in the facilitator’s role.
• Follow along with the debriefing script
DEBRIEFING
Questions/Wrap Up (25 min)
Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)
Break (10 min) Return in Small Groups
Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief
Break (10 min)
How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script
SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot
Welcome/Introductions (10 min)
Questions/Wrap Up (25 min)
Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)
Break (10 min) Return in Small Groups
Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief
Break (10 min)
How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script
SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot
Welcome/Introductions (10 min)
1. Break your small group into two groups (A&B)
2. Take 10 minutes to familiarize yourself with your case 1. Group A: Case 3A 2. Group B: Case 2B
3. Group A: Facilitate Case 3A for Group B
• 10 min case/10 min debrief
4. Group B: Facilitate Case 2B for Group A • 10 min case/10 min debrief
5. Group Feedback
Your Turn
Questions/Wrap Up (25 min)
Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)
Break (10 min) Return in Small Groups
Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief
Break (10 min)
How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script
SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot
Welcome/Introductions (10 min)
https://www.appd.org/amsurvey/