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Medical Education  |   August 2013
Incorporating Simulation Technology Into a Neurology Clerkship
Author Notes
  • From the Penn State Hershey Medical Center (Drs Ermak and Sinz), Anesthesia Associates of Lancaster, Ltd, in Pennsylvania (Dr Bower), the Penn State Hershey Clinical Simulation Center (Ms Wood), and the Penn State College of Medicine in Hershey (Dr Kothari) 
  • Address correspondence to David Matthew Ermak, DO, Penn State Hershey Medical Center, 30 Hope Dr, Hershey, PA 17033-2036. E-mail: dermak@hmc.psu.edu  
Article Information
Medical Education / Neuromusculoskeletal Disorders
Medical Education   |   August 2013
Incorporating Simulation Technology Into a Neurology Clerkship
The Journal of the American Osteopathic Association, August 2013, Vol. 113, 628-635. doi:10.7556/jaoa.2013.024
The Journal of the American Osteopathic Association, August 2013, Vol. 113, 628-635. doi:10.7556/jaoa.2013.024
Abstract

Simulation-based medical education is growing in use and popularity in various settings and specialties. A literature review yields scant information about the use of simulation-based medical education in neurology, however. The specialty of neurology presents an interesting challenge to the field of simulation-based medical education because of the inability of even the most advanced mannequins to mimic a focal neurologic deficit. The authors present simulator protocols for status epilepticus and acute stroke that use a high-fidelity mannequin despite its inability to mimic a focal neurologic deficit. These protocols are used in the training of third- and fourth-year medical students during their neurology clerkship at Penn State College of Medicine. The authors also provide a review of the pertinent literature.

Simulation-based medical education (SBME) is an evolving method of training that allows medical practitioners to learn and perform clinical skills and interventions in a safe and controlled reproducible environment that replicates real-world situations.1 The SBME method can involve a variety of aids including standardized patients, part-task mannequins (eg, a torso for cardiopulmonary resuscitation compression training), and whole-body advanced mannequins with high-fidelity capabilities.2 Such high-fidelity mannequins, like the one used at Penn State College of Medicine, are able to run preprogrammed scenarios that can be manipulated in real time by a proctor. For example, a proctor can give the mannequin a “voice” by using a voice box and can manipulate the mannequin's vital signs including heart rate, blood pressure, and intracranial pressure. High-fidelity mannequins can also display clinical signs, including palpable pulses, pupil and eyelid reactivity, and visible respirations. 
Medical educators are using SBME to teach communication skills, physical examination skills, identification of systemic problems, and clinical reasoning, as well as management of respiratory emergencies, advanced cardiac life support,3,4 management of shock,4 cardiac auscultation,5 and various clinical procedures such as central line placement, thoracentesis, and paracentesis.4 Simulators are also used to train medical professionals in rare clinical scenarios; for example, obstetrics and gynecology residents have used simulators to train for the management of magnesium toxicity and eclampsia.6 
Although countless uses of SBME for teaching surgical and interventional procedures have been described,3-6 published information regarding the use of simulation in neurology is scant, probably in large part because of the inability of high-fidelity mannequins to emulate focal neurologic deficits (eg, facial droop). This inability of high-fidelity mannequins is a substantial limiting factor in implementing SBME in neurology. At Penn State College of Medicine, however, we believe that SBME can be used for training in neurology despite the shortcomings of current simulator technology. In the present article, we describe Penn State College of Medicine's framework for using a high-fidelity mannequin to train medical students in 2 types of neurologic emergencies: status epilepticus and acute stroke (brain attack). 
Simulation-Based Education at Penn State College of Medicine
At Penn State College of Medicine, we use SBME in the training of third- and fourth-year medical students during their neurology clerkship. We developed 2 main simulations for training our students: (1) evaluation and treatment of a patient with status epilepticus and (2) evaluation and treatment of a patient who has had an acute stroke. We use a high-fidelity mannequin programmed with particular vital signs and pupil responses; this mannequin is accompanied by a formal neurologic assessment available on request by the students. In the status epilepticus scenario, we augment the experience by having an actor play the role of a family member who is able to provide collateral information. Each session lasts approximately 1 hour: the simulation itself lasts approximately 15 minutes, and the remainder of the time is spent on debriefing. 
In the status epilepticus simulation, students are provided general information about the case immediately before entering the simulation room. Once they enter, they are greeted by an actor playing the role of either the wife or son of the patient. The students are to question the actor to gather a complete medical history (Figure 1). As the students proceed with their evaluation of the patient, they can see the vital signs on the monitor that accompanies the mannequin and can ask for the findings of the neurologic examination. They are also expected to ask for the results of individual laboratory and imaging tests (Figure 1). Students who successfully complete the scenario will diagnose status epilepticus and initiate a proper treatment protocol (Figure 1). 
Figure 1.
Status epilepticus simulation protocol using a high-fidelity mannequin. This protocol is used by Penn State College of Medicine to train third- and fourth-year medical students during their neurology clerkships. a Liver function, toxicity screen, and blood alcohol content findings were available for select simulations. b The patient (ie, mannequin) is unable to talk initially, but after several minutes he is able to mumble. The patient appears disoriented and all history is obtained from his wife or son. Abbreviations: A, answer; Q, question; IV, intravenous; PE, phenytoin sodium equivalents.
Figure 1.
Status epilepticus simulation protocol using a high-fidelity mannequin. This protocol is used by Penn State College of Medicine to train third- and fourth-year medical students during their neurology clerkships. a Liver function, toxicity screen, and blood alcohol content findings were available for select simulations. b The patient (ie, mannequin) is unable to talk initially, but after several minutes he is able to mumble. The patient appears disoriented and all history is obtained from his wife or son. Abbreviations: A, answer; Q, question; IV, intravenous; PE, phenytoin sodium equivalents.
The acute stroke simulation has 2 scenarios (Figure 2). Students are provided basic patient history immediately prior to entering the simulation room. An actor can be available to provide collateral history, but it is not necessary; the physician facilitating the scenario can provide information regarding the patient's “last known normal” time. The students are provided formal neurologic examination findings on request. They are expected to ask for results of laboratory tests and computed tomography of the head, which are also available on request. Once the students are able to recognize the scenario as an acute stroke, they are asked to make decisions on management. In the setting of our first acute stroke scenario, the examination is consistent with brain herniation and the students are expected to withhold intravenous tissue plasminogen activator. In scenario 2, they are expected to administer the drug. 
Figure 2.
Acute stroke (brain attack) simulation protocol using a high-fidelity mannequin. This protocol is used by Penn State College of Medicine to train third- and fourth-year medical students during their neurology clerkship. a Intensive care unit (ICU) status requires the patient to remain in the intensive care unit for 24 hours for close monitoring of neurologic status with frequent neurology checks, frequent vital sign checks, and stringent blood pressure goals, with a systolic blood pressure goal of less than 180 mm Hg.
Figure 2.
Acute stroke (brain attack) simulation protocol using a high-fidelity mannequin. This protocol is used by Penn State College of Medicine to train third- and fourth-year medical students during their neurology clerkship. a Intensive care unit (ICU) status requires the patient to remain in the intensive care unit for 24 hours for close monitoring of neurologic status with frequent neurology checks, frequent vital sign checks, and stringent blood pressure goals, with a systolic blood pressure goal of less than 180 mm Hg.
After the simulations, the students are able to review a video recording of their scenario for self-assessment. The physician facilitating the scenario provides further feedback and encourages discussion, focusing on the points listed in Figure 1 and Figure 2. This step in the learning process allows for individualized instruction to address knowledge deficits that were identified during the simulation. 
Comment
As previously mentioned, simulation of stroke and seizure is difficult because of the inability of current simulators to mimic a focal neurologic deficit. For this reason, we ask that our students use their imaginations during the SBME sessions. The localizing features of the examination play a small role in the care of such a patient, however; recognition of the diagnosis and decisions regarding acute therapy (ie, intravenous tissue plasminogen activator) are based largely on factors other than the fine details of the neurologic examination. In both the acute stroke and the status epilepticus scenarios, our students are assessed on their evaluation of the situation, their recognition of vital sign abnormalities (eg, Cushing triad), their time management in obtaining pertinent laboratory and imaging test results, and their decision-making skills. By stressing the recognition and management of a neurologic emergency rather than the recognition of localizing symptoms, we believe we have found an effective way to use SBME in a neurology clerkship that is not limited by current technology. 
To our knowledge, few articles have been published regarding SBME in the field of neurology. The use of SBME for impending brain herniation with or without intracranial hypertension has been described in the literature, as this type of scenario does not necessitate the presence of a focal neurologic deficit other than an occasional pupillary asymmetry (which high-fidelity mannequins are currently capable of emulating).7 Simulations using part-task mannequins have been shown to improve lumbar puncture skills in neurology residents.8 Other uses of simulation in neurology have focused largely on critical care aspects including spinal shock, closed-head injury, and cerebral vasospasm. In these scenarios, a high-fidelity mannequin with real-time tracings of intracranial pressure and cerebral perfusion pressures was used. This mannequin was also equipped with a speaker box so that the proctor could speak for the simulated patient.9 
The first (to our knowledge) described simulation of a stroke used accompanying video clips of real stroke patients with focal neurologic deficits to make up for the mannequin's incapacity to mimic such deficits.10 It has been suggested that this type of work-around detracts from the believability of a scenario.7 Because of the complexity and variety of focal neurologic deficits that exist, virtual patient simulations using computer-based technology have begun to emerge as potential mediums for enhancing education through simulation. In 2009, researchers created a computer-based virtual patient simulator called the Neurological Exam Rehearsal Virtual Environment, or NERVE, which has been used to teach the assessment and diagnosis of cranial nerve abnormalities.11 
At Penn State College of Medicine, students are required to participate in the simulation scenarios as part of their curriculum. This requirement ensures that students gain experience in these scenarios, as the clinical variation during their rotation may not allow for adequate exposure. During the debriefing sessions, students participate in small groups in a lecture setting. A physician from the neurology faculty is present at each simulation to help guide the students through the scenario and to ensure a controlled environment. This faculty member also facilitates the postsimulation debriefing. 
Simulation-based medical education has been shown to be most effective when paired with a debriefing session after the simulation to allow for self-reflection and identification of knowledge deficits.6,12 A systematic review13 revealed that 47% of all journal articles on the topic of the effectiveness of simulation-based education identified feedback as an important step in the learning process. This step was identified as the most important of 10 conditions that represent ideal circumstances for effective SBME (Figure 3).13 Our students spend the majority of the 1-hour session on debriefing. This debriefing session is used to not only review what was done right and wrong, but also to integrate and affirm the newly learned information. Our program also has several of the other 10 conditions that are associated with effective learning in SBME, including integration into curriculum, controlled environment, clinical variation, and use of multiple learning strategies.13 These strategies for learning were shown to be effective in a 2012 systematic review and meta-analysis by Cook et al.14 
Figure 3.
Ten conditions that facilitate learning in simulation-based medical education.13
Figure 3.
Ten conditions that facilitate learning in simulation-based medical education.13
Simulation does not replace real patients, but it can help prepare students for real-life clinical scenarios.1 As shown in a 2011 meta-analysis15 by Cook et al of 609 studies on SBME, technology-enhanced education has been consistently associated with improved outcomes in knowledge, skills, behaviors, and even patient-related outcomes. In addition, SBME was endorsed as a method that is complementary to real patient-care experiences by the American College of Chest Physicians in their 2009 evidence-based guidelines on medical education.16 
Conclusion
Without the backbone of traditional educational activities such as lectures, SBME could not be effective on its own; however, SBME can be used as an adjunct to train students in important clinical scenarios that they may not otherwise be exposed to in their clinical rotations. The scenarios described in the present article provide a framework for how SBME can be used in neurology despite the shortcomings of current technology. No outcome measures have been addressed, however. Further investigation is needed to determine the efficacy of our scenarios on educational outcomes. 
   Financial Disclosures: None reported.
 
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Fisher N, Bernstein PS, Satin Aet al. Resident training for eclampsia and magnesium toxicity management: simulation or traditional lecture [published online ahead of print August 5, 2010]? Am J Obstet Gynecol. 2010;203(4):379.e1-379.e5. doi:10.1016/j.ajog.2010.06.010. [CrossRef]
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Barsuk JH, Cohen ER, Caprio T, McGaghie WC, Simuni T, Wayne DB. Simulation-based education with mastery learning improves residents' lumbar puncture skills. Neurology. 2012;79(2):132-137. [CrossRef] [PubMed]
Musacchio MJJr, Smith AP, McNeal CAet al. Neuro-critical care skills training using a human patient simulator. Neurocrit Care. 2010;13(2):169-175. [CrossRef] [PubMed]
Garside MJ, Rudd MP, Price CI. Stroke and TIA assessment training: a new simulation-based approach to teaching acute stroke assessment. Simul Healthc. 2012;7(2):117-122. [CrossRef] [PubMed]
Johnson TR, Lyons R, Chuah JH, Kopper R, Lok BC, Cendan JC. Optimal learning in a virtual patient simulation of cranial nerve palsies: the interaction between social learning context and student aptitude. Med Teach. 2013;35(1):e876-e884. doi:10.3109/0142159X.2012.714884. [CrossRef] [PubMed]
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Figure 1.
Status epilepticus simulation protocol using a high-fidelity mannequin. This protocol is used by Penn State College of Medicine to train third- and fourth-year medical students during their neurology clerkships. a Liver function, toxicity screen, and blood alcohol content findings were available for select simulations. b The patient (ie, mannequin) is unable to talk initially, but after several minutes he is able to mumble. The patient appears disoriented and all history is obtained from his wife or son. Abbreviations: A, answer; Q, question; IV, intravenous; PE, phenytoin sodium equivalents.
Figure 1.
Status epilepticus simulation protocol using a high-fidelity mannequin. This protocol is used by Penn State College of Medicine to train third- and fourth-year medical students during their neurology clerkships. a Liver function, toxicity screen, and blood alcohol content findings were available for select simulations. b The patient (ie, mannequin) is unable to talk initially, but after several minutes he is able to mumble. The patient appears disoriented and all history is obtained from his wife or son. Abbreviations: A, answer; Q, question; IV, intravenous; PE, phenytoin sodium equivalents.
Figure 2.
Acute stroke (brain attack) simulation protocol using a high-fidelity mannequin. This protocol is used by Penn State College of Medicine to train third- and fourth-year medical students during their neurology clerkship. a Intensive care unit (ICU) status requires the patient to remain in the intensive care unit for 24 hours for close monitoring of neurologic status with frequent neurology checks, frequent vital sign checks, and stringent blood pressure goals, with a systolic blood pressure goal of less than 180 mm Hg.
Figure 2.
Acute stroke (brain attack) simulation protocol using a high-fidelity mannequin. This protocol is used by Penn State College of Medicine to train third- and fourth-year medical students during their neurology clerkship. a Intensive care unit (ICU) status requires the patient to remain in the intensive care unit for 24 hours for close monitoring of neurologic status with frequent neurology checks, frequent vital sign checks, and stringent blood pressure goals, with a systolic blood pressure goal of less than 180 mm Hg.
Figure 3.
Ten conditions that facilitate learning in simulation-based medical education.13
Figure 3.
Ten conditions that facilitate learning in simulation-based medical education.13