simulation in radiology - car€¦ · linda probyn, md, frcpc eric bartlett, md, simulating real...

Simulation in Radiology

Linda Probyn, MD, FRCPCEric Bartlett, MD,

Simulating Real Life Challenges

Disclosures

• Linda Probyn – none• Eric Bartlett – none

Learning Objectives

1. Describe various types of simulation that can be used in radiology education

2. Discuss how simulation in radiology can be used as an assessment tool to improve performance

Simulation in Radiology

• Use of simulation to train residents is ↑’ing in Medical Education

• Fewer hands on experiences:– Decrease hospital length of stay– Restrictions on duty hours– Decreased resident autonomy– Productivity pressures– Patients’ awareness of trainees “practicing” on

them

Simulation in Radiology• Simulation allows:

– Trainees to practice a procedure or scenario before doing on actual patients

– Evaluation of trainees to assess readiness for the “real world”

• Cons:– Not “exactly” the same– Can’t anticipate all scenarios– $$

Simulation in Radiology – Types

• Procedural• Nonprocedural

– Interpretative & Computer based

– Team based & Crisis Management

– Professional & Communication– Hybrid– In-situ

→ ER Sim

Acute Emergencies in Radiology

• Rare in the Radiology Dept• But Residents often first responders (esp. after

hours)• Little ability to train• Simulation useful


• PGY2s – 3 hour simulation– Contrast reaction– Seizure– Cardiac arrest

• Didactic lecture• Debrief


• Evaluation pre-, immediately post- and 1 year post-simulation


• Resident knowledge and comfort improved post-simulation, esp. in non-contrast reaction related simulation

• Returned to baseline knowledge 1-year post simulation

• Residents need frequent exposure to managing acute emergencies

Hybrid Simulation• More than one type of simulator used• Common to use manikin with

standardized patient

Technologist

Hybrid Simulation• Increased realism of scenario• More complex and challenging• Assess several domains

Technologist

In Situ Simulation• Simulation in clinical

environment• Close to real life

experience• Usually involves health

care team

In Situ Simulation• Reveals local system

challenges• Complex environment• Assess several domains

Simulating Real Life Challenges

‘Training mirrors practice’

‘Training mirrors practice’• CBD concept• Residency programs:

• Training curriculum• Goals/Objectives• On-the-job

• Assessments focus on ‘Medical Expert’

• Assessment gapEntrustable Professional

Act (EPA)

ACR Exam

Mock Oral

ITER

OSCE

CBD, a different type of assessment• Emergency radiology

• Challenge: how can we be sure that PGY2 residents are ready to cover after-hours on-call activities?

• On-line simulation program• Goal: address ‘challenge’ (summative assessment)

and demonstrate all tasks/components of the job that are required for a resident to be ‘competent’ at after-hours on-call work (formative assessment).

Challenge #1Demonstrating competency

in emergency radiology.

(. . . a future EPA?)[EPA = Entrustable Professional Act]

After-Hours:• Different After-Hours structures/preparation across Canada

• Ultimately, similar work:

• Residents work on PACS units to prioritize/protocol cases, interpret studies, enter preliminary diagnoses, and to record critical results reporting.

• High stress—preliminary diagnoses from residents are acted upon. Quick turn-around-time.

the simulationER SIM:

Emergency Radiology SIM:• 4-hour on-line exam (2016: PGY2-5)• Simulated a 4-hour After-Hours Shift:

• Protocol cases• Prioritize cases• Manage a worklist• View full cases• Type preliminary reports• Critical results reporting• Answer ‘pages’• Provide recommendations• Keep a log book of cases/diagnoses• Prepare a handover document

Emergency Radiology SIM:• Assessment:

• Summative—are the skills and knowledge at expected level to allow for increased role and responsibility? EPA?

• Formative—demonstration of all the tasks and skills needed to successfully complete an After-Hours Shift (an experiential ‘walk-through’ of the job).

• Articulate—Interactive e-learning software• Develop educational modules• Deliver quizzes• Create simulations• Analytics to track learners

• Vimeo—Video hosting• Used to host DICOM series

Emergency Radiology On-line Simulator Demo

Emergency Radiology SIM:

http://ut-medical-imaging.articulate-online.com/6942487566

Examples: Main page

Examples: Protocol

Examples: Paging

Examples: Prioritize

Examples: Protocol

Examples: PACS Worklist

Examples: PACS Image Viewer

Examples: Reporting

Examples: Critical Results

Examples: Paging

Examples: Handover

the resultsFidelity & Findings:

“Fidelity” in simulation:• How closely the appearance and behaviour

of the simulation resembles reality

• contextual fidelity = psychological fidelity =

meaning/learning

Fidelity—Emergency Radiology SIM:Real Life Challenges: On-Call: ER SIM:Accept handover

Protocol cases

Prioritize cases

Manage worklist

Answer pages

View full DICOM cases

Preliminary reports

Critical results reporting

Provide recommendations

Log cases/tasks

Prepare next handover

Fidelity—Answering ‘pages’:Real Life Challenges: On-Call: ER SIM:

Disruption

Varied scenarios

Interpersonal interactions

Managing conflict

Managing unexpected

Dynamic interaction

Feedback

Fidelity—View full DICOM cases:Real Life Challenges: On-Call: ER SIM:

Complete DICOM

All planes/sequences

Prior imaging

Fast, seamless review

PACS toolkit

Simultaneous view/reportX

Emergency Radiology SIM Results:• Preliminary results:

• Medical Expert:• Performance improved every year, with less

profound change between PGY4 and PGY5.• Identified one PGY2 resident needing remedial work.

• Communicator—improves throughout residency.• Collaborator:

• Ability for resident to properly recommend ‘next steps’ for patient—did not improve after PGY2 year.

• Protocolling exams—relatively poor performance.• Advocate—good performance across PGY-levels.• Professional—difficult to test.

• Determining On-call ‘readiness’ (EPA fulfillment):• Excellent

• Answering ‘pages:• Poor

• View full DICOM cases:• Good—technical challenges, solutions pending

Fidelity—Overall:

Resident Feedback: Satisfaction Survey

80%

60%

90%

67%

87%

87%

86%

85%

Tips/TricksLessons Learned.

Guidance.

Bumps in the Road:• Software and Hosting packages are expensive• Dependent on 3rd party programs (Articulate, Vimeo, etc.)• Need computer lab with appropriate hardware• Dependent on properly functioning high-speed Internet

• Data overload!• Help to score cases• Develop a scoring matrix

How to make it all happen:• Team effort• Learners must see relevance

• “High Fidelity”• Resources (software, LMS)• Educational research/Scholarly activity• CBD deadlines help

• 2017—trial roll-out to other programs• Research collaboration• Unmasked some technical issues

• 2018 goals:• Rework ER Sim to address technical issues and improve

the virtual PACS, new cases and scenarios• Continue roll-out across Canada• Add qualitative component to research collaboration

Next Steps:

• Ultimate goal: • Solution to assessment gap in CBME• Better understanding of CBD before 2019 meeting

with the Royal College• Use various modes of simulation to enhance

residence skills to prepare for training and practice

Next Steps:

Questions/Comments?

#TorontoStrong

The EndLinda Probyn, MD FRCPC

[email protected]

Eric Bartlett, [email protected]

mailto:[email protected]

mailto:[email protected]

References• Chelten AL, Mendriatta-Lala M, Probyn L, Auffermann WF, DeBenedectis CM. et. al.

Conventional Medical Education and the History of Simulation in Radiology. Academic Radiology 2015; 22(10):1252-1267.

• Petscavage JM, Paladin AM, Wang CL, et al. Current status of residency training of allergic-like adverse events to contrast media. Acad Radiol 2012; 19(2):252-5.

• Sarwani N, Tappouni R, Flemming D. Use of a Simulation Laboratory to Train Radiology Residentsin the Management of Acute Radiologic Emergencies. ARJ Am J Roentgenol 2012; 199(2):244-51.

• Tofil NM, White ML, Grant M, et al. Severe contrast reaction emergencies: High-fidelity simulation training for radiology residents and technologists in a children’s hospital. Acad Radiol 2010; 17:934-940.

• Tubbs RJ, Murphy B, Mainiero MB, et al. High-fidelity medical simulation as an assessment tool for radiology residents’ acute contrast reaction management skills. J Am Coll Radiol 2009; 6:582-587.

simulation in radiology - car€¦ · linda probyn, md, frcpc eric bartlett, md, simulating real...

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