Wake Forest University School of Medicine
Winston Salem, NC
Edward Haponik, MD
During the past two years the use of multimodality simulation has become a major component of the renewal of Pulmonary/Critical Care Fellow education at Wake Forest University School of Medicine, and has complemented the experiences focused on traditional hospital service-based clinical rotations. This curricular initiative represents a partnership of Fellow and Faculty delineation and prioritization of learning needs and application of dynamic, novel resources in our Medical Center’s Center for Applied learning (CAL; see attachment). Components of the latter have included cadavers prepared especially to represent specific respiratory problems; high-fidelity anatomic models and other devices developed to promote motor skills, procedural competencies, and real-time clinical decision making; and a computer-based curriculum incorporating video-based instruction. Our individualized learning goals were defined, focused upon knowledge, skills, attitudes and behaviors in areas that required improvements in the Fellow experience. We prioritized areas for these activities based upon internal and external (RRC) review of our program, together with computer-based needs assessment by Faculty and Fellows.
One example of an especially productive experience evolved from the need for augmented Fellow instruction in the placement of chest tubes. Although this procedure has always been available to Fellows during their rotations on CT Surgery, Trauma, and oncology services, it represented an opportunity for improved instruction. Surveys of Faculty and Fellows confirmed that this was a valued area for our curriculum, and a focused experience in our CAL simulation laboratory was designed. Pretest surveys confirmed suboptimum appreciation of specific details of the procedure, and prospective assessments documented a low frequency of chest tube placement by Fellows. To assure participation in this training experience, Fellows were relieved of their clinical responsibilities and covered by Faculty so that they could attend two blocks of instruction in our cadaver laboratory. In an experience coordinated with our program’s expanded use of ultrasound, each Fellow had hands-on direct instruction by faculty who also observed their performance in the placement of chest tubes, rigid bronchoscopy, pleuroscopy and percutaneous tracheostomy. Fellows received immediate feedback from Faculty following this direct instruction. Fellows’ self-assessments and knowledge were retested with a written examination, and had improved.
This initial positive experience has been followed by the expanded use of the Center for Applied learning in other major areas, including Fellow instruction in placement of central venous catheters, critical care ultrasound, and interventional bronchoscopy procedures. This approach has also promoted new multidisciplinary interactions including sessions on management of difficult airways (coordinated with our Department of Anesthesia); tracheostomy care (Department of otolaryngology); and, in a team experience partnered with our Department of obstetrics/gynecology, emergency management of a simulated critically ill patient during pregnancy. Reinforcement of instruction has been achieved through repeated training experiences, with the latter modified and refined by feedback from participating Fellows, and Faculty. We believe that this novel, memorable instruction and objective evaluation applying CAL resources to Pulmonary/Critical Care has complemented and enriched our Fellows’ clinical experiences, and has made a major, durable impact upon Fellow education.
