Simulation training in medicine articles. The use of simulation technologies in classes in the specialty "general medicine"
The article discusses current issues of using simulators in practical training of junior medical students in preclinical training rooms at the Department of Nursing and Clinical Care. On modern stage Simulation training is widely recognized as an important component of medical training and as a fundamental approach to ensure patient safety. During educational process special attention is paid to the ability and readiness to implement professional knowledge, skills and abilities necessary in the further professional activities of the future doctor, pharmacist, social worker. The article lists the available simulators, and also clearly reflects all levels of organization of simulation training for students. Significant issues are also the improvement of educational and methodological materials. An analysis of the effectiveness of using simulation technologies during educational practice students majoring in General Medicine.
simulator
simulation training
practical skills
educational process.
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3. Kostrova I.V., Prikhodko O.B., Khodus S.V. The role of the simulation and certification center in the training of students of the Amur State Medical Academy // Collection of scientific works “University pedagogy”. - Krasnoyarsk, 2016. - P.384-386.
4. Muravyov K.A., Khodzhaev A.B., Roy S.V. Simulation training in medical education – a turning point // Basic Research. – 2011.– No. 10-3. - P.534-537.
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At the present stage, simulation technologies in medicine are the optimal training format with a strong emphasis on mastering practical skills. Therefore, it is natural that one of the main directions in the field of higher medical education is the need to significantly strengthen the practical aspect of training future doctors while maintaining the proper level of theoretical knowledge. It is the state of the student’s clinical training that is characterized, in our opinion, as a very complex and “sore” issue in the work of any university, regardless of its status and size. On the one hand, the growing demands of new government educational standards To professional competencies graduates, and on the other hand, the unresolved problems of clinical departments, which experience well-known difficulties in their work, largely complicate the training of specialists already at the initial stages of clinical training. In this regard, the emergence of opportunities in organizing phantom and simulation training for students seems to us as a reasonable and necessary direction in the educational process. We want to emphasize this specifically for students, starting from the first year, and not just for certain groups of residents and interns. For junior students, medical care is a medical activity to ensure optimal conditions for recovery and therefore requires the same serious development by students of medical specialties as all other elements of medical activity. Before studying clinical disciplines, students must familiarize themselves with and master the necessary manipulations and procedures of medical care, and be able to provide emergency first aid. Today, mastering most skills and manipulations, especially those associated with the risk of complications during their implementation, is possible only in a theoretical format. And at the same time, every university graduate is required to confidently carry out a number of technical techniques aimed, first of all, at saving lives. In this regard, there was a need to create and widely implement an innovative approach to training and professional retraining personnel. The traditional system of practical training in the healthcare sector has a number of disadvantages, which are mitigated by simulation training. In existing laws and standards regulating the training of medical workers (Federal Law Russian Federation dated November 21, 2011 N 323-FZ "On the fundamentals of protecting the health of citizens in the Russian Federation", Federal state requirements for the training of specialists), states that practical training of students is provided through their participation in medical activities under the supervision of workers educational organizations. The patient must be informed and have the right to refuse the participation of students in the provision of medical care. It is becoming increasingly difficult to obtain patient consent for students to participate in their medical care. With the introduction of market relations in clinics and changes in the legislative framework during the training of specialists, it is necessary to redistribute training time in such a way that mandatory simulation training modules appear between theoretical training and participation in medical activities. High modern requirements for the development of practical skills by medical students, for updating educational material and bringing the educational environment closer to the new environment of practical healthcare make virtual technologies in medical education a key direction in the development of higher medical schools.
Purpose of the study: to analyze the effectiveness of using simulation technologies in the development of practical skills and the formation of professional competencies during educational practice in nursing among junior students.
Material and research methods. 237 1st year students of the Faculty of Fundamental Medical Education (FFME) - General Medicine took part in the survey while undergoing training practice “General nursing for therapeutic patients.” The survey was anonymous, each student could express their opinion on organizing educational practice, working with simulators and mastering professional skills. The questionnaire contained 12 questions.
Research results and discussion. Clinical Department of Nursing and Clinical Care (SD and CU) Krasnoyarsk State Medical University named after. prof. V.F. Voino-Yasenetsky is multidisciplinary, since the educational process is conducted at several faculties simultaneously. The department has organized two simulation training classes, where students develop and practice practical skills in educational practice classes in the junior years of FFME - General Medicine, Pediatrics, Dentistry, as well as at the Faculty of Pharmacy and the direction of training - Social Work. The Department of Diabetes and Health Care actively integrates organizational and methodological work with the College of Pharmacy of our university.
The department has a sufficient number of simulators for working with students as part of educational practice: interactive mannequins of an adult patient in human size for practicing practical skills in personal hygiene and emergency first aid;
interactive newborn mannequins and six-month baby mannequins to practice childcare skills; models for adults to master pre-medical care for cardiopulmonary pathology; simulators for all types of injections; simulators for performing nursing manipulations: practicing bladder catheterization; administering enemas, compresses; nasogastric zoning, etc.; kits for the prevention and treatment of bedsores, etc.
Considering that educational practice involves the acquisition of practical skills within the framework of a competency-based approach under the supervision of teachers, from the experience of our work, some methodological approaches to the development of practical skills and the formation of professional competencies using simulation technologies have emerged.
The organization of work during educational and practical classes was based on a 6-level scheme:
Level 1. Theoretical introduction
Students receive the topic of the lesson, independently work through theoretical aspects, based on guidelines for classroom and extracurricular activities.
Level 2: Observation of implementation
In preparation for the lesson, watch the video material of the practical skill. In the methodological recommendations there is a paragraph - practical skills for each lesson.
Level 3. Working with algorithms
They independently compile their own algorithm for performing practical skills on the relevant topic, using the algorithms posted on the department’s website.
Level 4: Complete theoretical understanding
During educational and practical classes, within 10-15 minutes, questions on the topic of the lesson are discussed and clinical problems are solved. Testing is underway.
Level 5. Demonstration of skill by teacher
During the training session, after theoretical analysis, the teacher slowly demonstrates practical skills on simulators.
Level 6. Execution (on simulators)
Further, during the training session, students practice practical skills in pairs, using checklists of algorithms developed by teachers of the department, bringing them to automaticity, and evaluate themselves independently, checking the checklist.
The teacher monitors the process of mastering skills, correcting mistakes that students have not noticed. After mastering a block of professional skills, students participate in the treatment process in the therapeutic departments of hospitals, where they implement developed practical skills under the guidance of a teacher and nursing staff of the clinic at the patient’s bedside.
After analyzing the student survey, the following results were obtained:
To the question “Did you use the teaching materials posted on the department’s page to master practical skills?” students responded positively (78.4%), did not use (10.5%) and did not know about their existence (10.9%), which is reflected in Fig. 1.
Rice. 1. Students’ use of teaching materials posted on the department’s website
These answers indicate the benefits of the posted methodological material; Students who missed classes at the beginning of practice did not know about the existence of manuals on the site.
To the question, “Did you use the video bank of practical skills to master practical skills? ", (85%) students responded positively, (8%) students could not access the university website, forgot their password, but knew about the existence of the data bank, (7%) did not use the university website, which is presented in Fig. 2.
Rice. 2. Students’ use of the video bank of practical skills on the university website
76.4% of students responded that practicing injection skills most used the resource with a video bank of practical skills.
To the question “How do you assess the level of equipment of the department on a 5-point scale?”, (54.6%) students gave 5 points, thereby noting a high resource; (34.3%) answered a sufficient level (4 points), and (11.1%) students answered 3 points: they expressed a desire to have more simulators, for some skills there are not enough simulators (for example, gastric lavage), and they have to concentrate on groups for training are not two, but 4-5 people, as shown in Fig. 3.
Rice. 3. Students’ assessment of the department’s equipment
To the question “Do simulators help you in mastering practical skills”? in (100%) a positive answer was received, which is presented in Fig. 4
Fig.4. Evaluating the effectiveness of simulators
To the question “Are you ready for the upcoming summer production practice"? students expressed their readiness by 5 points, which amounted to (44.5%), by 4 points - (55.5%), which is presented in Fig. 5. Students were concerned about filling out documentation and adapting to an unfamiliar team.
Rice. 5. Students’ readiness for upcoming practice
(74.5%) students noted their independence during educational practice, (22.6%) noted activity only in the presence of a teacher, and (2.9%) percent stated a lack of interest in classes.
1.Training with the help of simulators is one of the effective teaching methods in the development of practical skills and the formation of professional competencies of junior students in medical school.
2. A properly organized methodological approach of the staff of the department and the College of Pharmacy: the use of methodological developments of algorithms for practical skills, a video bank of practical skills, makes the acquisition of skills faster and clearer, automaticity and correct execution of the skill are laid down.
3. The correct organization of the educational process of practice using simulation technologies leads to the mastery of professional practical skills at a higher level than the theoretical description of the latter, or the presence of first-year students in the department, when “they are not allowed to do anything except wet cleaning of premises.”
4.The effectiveness of training using simulation methods is confirmed independent work students within the framework of educational and practical classes in therapeutic departments at the clinical bases of the department and the readiness of students for summer practical training.
Bibliographic link
Turchina Zh.E., Sharova O.Ya., Nor O.V., Cheremisina A.V., Bitkovskaya V.G. SIMULATION TRAINING AS A MODERN EDUCATIONAL TECHNOLOGY IN THE PRACTICAL TRAINING OF JUNIOR COURSE STUDENTS OF A MEDICAL UNIVERSITY // Contemporary issues science and education. – 2016. – No. 3.;URL: http://science-education.ru/ru/article/view?id=24677 (access date: 02/01/2020). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"
Three paths lead us to the heights of wisdom:
the path of reflection is the noblest,
the path of imitation is more accessible than all others
and the bitter path is based on your own mistakes.
Confucius, 5th century BC
In the modern world, in the era of rapid development of high-tech medicine, society places increased demands on the quality of medical services. It is this indicator and the quality of life of patients after treatment that should form the basis for assessing the professional activities of individual specialists and medical institutions, as well as the level of healthcare in general.
The classical system of clinical medical education is not able to fully solve the problem of high-quality practical training of a medical worker. The main obstacles to this are the lack of continuous feedback between the student and the teacher.
Therefore, the key task of modern secondary, higher and postgraduate medical education is to create conditions for students to develop a wide range of competencies and firmly established practical skills without the risk of harm to the patient.
This includes developing the health care professional's ability to make quick decisions and perform a series of procedures or interventions flawlessly, especially in emergency situations.
One of the methods for improving the quality of practical training of future paramedics, nurses, midwives, and medical laboratory technicians is the use of simulation technologies. Simulation in medical education is a modern technology for teaching and assessing practical skills, abilities and knowledge, based on realistic modeling, imitation of a clinical situation or a separate physiological system, for which biological, mechanical, electronic and virtual (computer) models can be used.
The Federal State Educational Standard for Secondary Professional Education in the specialty allocates laboratory practical classes (LPZ) for the development of practical skills through the introduction of simulation technologies, as a stage of preparation for academic (EP) and industrial practice (PP).
Currently, according to the level of realism, seven groups of simulation technologies for teaching medicine are distinguished. The advantages of simulation training at the present stage of medical development are beyond doubt.
- Visual: classic teaching aids, electronic textbooks, educational computer games.
- Tactile: simulators for practicing practical skills, realistic phantoms of organs, cardiopulmonary resuscitation (CPR) mannequins, for example, a phantom for practicing tracheal intubation.
- Reactive: mannequins of the lowest class of realism (Low-Fidelity).
- Automated: mid-range realistic mannequins, video equipment.
- Hardware: a middle-class simulator in a ward equipped with medical furniture and equipment, a simulator equipped with real medical equipment
- Interactive: robotic patient simulators of the highest class of realism (High Fidelity) and virtual simulators with tactile feedback.
- Integrated: complex integrated simulation systems - interacting virtual simulators.
When exchanging experience with colleagues from Kazan and Tabolsk medical colleges, we saw that these educational institutions have a multidisciplinary simulation center, which was created as a mini-clinic model and includes: a patient reception room, a treatment room, a dressing room, an intensive care ward, and an antenatal clinic room. , delivery room, healthy child room, enema room, test collection room.
In our educational institution, teachers dream of creating a full-fledged simulation center equipped with virtual simulators. IN medical college elements of simulation technologies are used in the form of electronic textbooks, educational computer games, practical skills simulators, realistic phantoms of organs, cardiopulmonary resuscitation mannequins, and development of auscultation techniques.
For more efficient use of simulation technologies, an “integrated” office was organized on the basis of the Bryansk State Autonomous Institution city Hospital No. 1”, where a kit for practicing practical skills in PM is assembled. 01 “Diagnostic activity”, PM. 02 “Medical activity”, which is used when training students in the specialty “General Medicine”.
One of the richest experiences in using simulation technologies has been accumulated by PM teachers. 07 “Performing work in the profession of a junior nurse caring for patients,” which at the hospital use the following levels of simulation equipment to practice manipulations:
1. Visual - introduces practical actions, their sequence and the technique of performing the manipulation. Students develop an understanding of the sequence of actions to perform a manipulation, but no actual practical practice of the manipulation occurs. But, this level allows you to move on to the next stage - to the actual practical development of the manipulation. An example would be electronic manuals and videos.
2. Tactile - occurs at this level
reproduction and development of practical skills, i.e. a sequence of coordinated movements during the performance of a particular manipulation and, as a result, the acquisition of a practical skill. An example is practicing manipulations on a phantom, a dummy and a standardized patient, whose role is played by a student.
3. Reactive - the simplest active reactions are reproduced
phantom on typical student actions. For example: when indirect cardiac massage is performed correctly, a light comes on, thereby assessing the accuracy of the student’s actions and reproducing the motor skills of a separate basic skill.
The final performance of manipulations using the above simulation equipment is possible using an objective scoring system.
Thus, the methodological task of our teaching staff for the near future, the “maximum program”, is the development of an “end-to-end” educational technology for the formation of each skill using models (phantom, mannequin, dummy, etc.), standardized patients with continuity and repeatability on each at the subsequent stage of training, as well as upon admission of students to the UE, PP or during certification based on the results of the PP.
But we can confidently emphasize in conclusion that simulation training is not an alternative to “live” communication with the patient, but a means to make this communication more effective and comfortable for the patient and the student, because in order to master the main types of professional activities for a medical worker, it is necessary not mannequins, but real, real patients.
1The problem of simulation training in medical education at the present stage is analyzed. A scheme is presented for integrating the simulation training system into the educational process for I–VI year students in the specialties “General Medicine” and “Pediatrics”, which is used in the established Center for Practical Skills of St. State Medical Academy. The necessity of creating large multidisciplinary educational and methodological units in the format of educational and simulation centers for clinical training of students and young specialists in medical universities is substantiated, with the implementation in the educational process of clearly defined clusters of practical training at all stages of training, including pre-university. The importance of using simulation technologies in teaching large student populations is especially emphasized.
simulation training
practical skills center
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3.National Growth in Simulation Training within Emergency Medicine Residency Programs / Y. Okuda et. al. // Acad. Em. Med. - 2008. - No. 15. - R. 1-4.
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The implementation of priority national projects in the healthcare sector, the processes of reform and modernization of the industry have revealed with particular urgency the problem of professional training of medical workers.
Everywhere in the industry there is an acute shortage of highly qualified specialists. Therefore, it is natural that one of the main directions in the field of higher medical education is the need to significantly strengthen the practical aspect of training future doctors while maintaining the proper level of theoretical knowledge.
It is the state of the student’s clinical training that is characterized, in our opinion, as a very complex and “sore” issue in the work of any university, regardless of its status and size. On the one hand, the growing requirements of new state educational standards for the professional competencies of graduates, and on the other, the unresolved problems of clinical departments, which are experiencing well-known difficulties in their work, largely complicate the training of specialists already at the initial stages of clinical training.
When passing clinical disciplines, it is not always possible to carry out a full analysis of each of the supervised patients, and even more so the teacher’s control over the quality of each student’s performance of an objective examination of the patient. In a real clinic, this situation is aggravated by the lack of individual provision of students with thematic patients and forced work in a group. IN last years the situation is aggravated by the widespread introduction of market relations in clinics and changes in the legislative framework.
In this regard, the emergence of opportunities in organizing phantom and simulation training for students seems to us as a reasonable and necessary direction in the educational process. We want to emphasize this specifically for students, starting from the first year, and not just for certain groups of residents and interns.
Currently, simulators are used for training and objective assessment of students in many areas of human activity that involve high risks.
Simulation training methods in medicine have been known for a long time; in particular, in anesthesiology, mannequins have been used since the 80s of the 20th century. The use of simulators, mannequins, and phantoms allows you to repeatedly practice certain exercises and actions while providing timely, detailed professional instructions during the work.
It is simulators that can repeatedly and accurately recreate important clinical scenarios and the ability to adapt the training situation to each student.
However, in the literature available to us, we found little convincing evidence for the use of simulations in linear undergraduate education programs. New state educational standards and “by-laws” do not at all define the role and place of simulation training in the educational process; the methodology and didactics of teaching are not defined.
Each university moving in this direction at its own “peril and risk” is now deciding the issues of staffing and organizing the work of simulation training, often experiencing resistance even in its own teams - the evidence base for the effectiveness of using simulators is not yet sufficiently developed, their cost is high, time costs and resistance are significant changes, but the process of creating simulation training centers is being carried out, including in medical universities.
The first modest steps in the work of the center for practical skills of the Stavropol State Medical Academy showed the feasibility of investing material resources in the implementation of the idea of creating a center and received a positive response from many representatives of the teaching staff of our academy.
It is now clear that the role of the center will not be reduced only to a room equipped with special phantoms. The center is an educational and methodological unit where not only individual practical skills and manipulations will be practiced, but also educational and methodological work, scientific research, experimentation in teaching technologies will be carried out with access to clinical bases and paraclinical departments. Thus, ideally, this is the path to creating a unified educational and simulation center for clinical training of students and young professionals, where clearly defined clusters of practical training will be implemented at all stages of training, including pre-university.
We see these main clusters as follows: “emergency medicine”, “patient care”, “pediatrics - emergency care, child care”, “anesthesiology and resuscitation”, “surgery and laparoscopy”, “obstetrics and gynecology”. Currently, the center has begun full-fledged work with a new school year according to the established regulations.
The first stage that students will go through at the training center is theoretical training - this is a specially designed special course in one of the sections of medicine. For example, these are recommendations for basic or advanced life support - Guidelines ERC or AHA 2005.
After this, students move to training rooms to master practical skills, where simulators for practicing individual medical procedures are collected by topic: vascular access, restoration of the patency of the upper respiratory tract, cardiopulmonary resuscitation, puncture of pneumothorax, immobilization and transportation, catheterization of the bladder, gastric lavage, nursing for stomas and catheters, auscultation, gynecological and obstetric manipulations.
This is followed by the stage of computer simulation, when, in a classroom environment, the student must go through certain modules of interactive curriculum(cardiac arrest, respiratory disorders, arrhythmias, poisoning and overdose, metabolic disorders and thermoregulation).
And then, having theoretical training (first stage), mastering practical skills (second stage) and having worked out a virtual algorithm for treating emergency conditions, the student ends up in the simulation part of the center (imitation ward), where, in conditions close to the real ones (real situation, real equipment) , a mannequin that independently responds to his interventions), he, through repeated repetition and analysis of mistakes, achieves the perfection of his psychomotor skills, skills in working with equipment and patients, and teamwork skills.
Junior year students who are preparing for nursing practice, before working in a hospital, must master not only the skills of caring for a patient, but also the basic resuscitation complex and the basics of providing emergency care for major critical conditions (suffocation, hypertensive crisis, fainting, etc. ) This is necessary so that the student feels more confident when working with patients, i.e. The educational process at the center will be structured so that by the time the student transfers to the clinical departments, he will have fully mastered the theory and practiced manipulations and clinical techniques on mannequins and simulators in accordance with the requirements of state educational standards in the specialties of general medicine and pediatrics. For example: currently, the teaching of the discipline “Resuscitation and Intensive Care” at the Faculty of Pediatrics is carried out in the 3rd year (2 hours - CPR training), in the 5th course in the 10th semester (prehospital stage of emergency care for the most common pathology in the volume 24 hours) and 6th course in 11-12 semesters (hospital stage of emergency care in the amount of 36 hours). There is also a lecture course. According to the decision of the Academic Council of the Stavropol State Medical Academy, in order to improve the acquisition of practical skills at the patient’s bedside, practice in ambulance and emergency care was approved for 6th-year students of the Faculty of Pediatrics (one night shift).
According to the requirements of Federal State Educational Standard 3 for the training of pediatricians, even more attention should be paid to students’ mastery of practical skills.
Also, according to the training program, teaching to pediatricians should be carried out in the discipline “Anesthesiology and Resuscitation” in the 11th-12th semester of study in the amount of 2 credit units + 1 unit for independent work.
Considering the complexity of the discipline being studied, it is not possible to fit two large sections of teaching into the specified amount of hourly workload while maintaining the quality of teaching practical skills.
In addition, the exam in the section of resuscitation and intensive care is taken by 5th-year students of the Faculty of Pediatrics during a comprehensive exam in pediatric surgery in the 10th semester, that is, before completing a course of practical training according to the new educational standard.
Taking into account the above, since September 2011, a decision was made to allocate 1.5 credit units to train 5th-year students of the Faculty of Pediatrics in practical skills at the Center for Practical Skills in the section “Anesthesiology”. At the 6th year of the Faculty of Pediatrics, issues of providing resuscitation and emergency care at the hospital and prehospital stages are resolved at the patient’s bedside training bases course. The skills are taught by course teachers due to their extensive practical experience.
We offer a work plan and a list of practical skills studied at the Center.
3rd year of all faculties - lesson volume 2 hours
Carrying out primary cardiopulmonary resuscitation on mannequins at the prehospital stage with mandatory quality control of skill acquisition;
Passing a test before undergoing nursing practice in order to be admitted to its completion.
5th year of the Faculty of Pediatrics - the volume of classes is 24 hours per group (one week of classes in the 10th semester)
Rules for working with a defibrillator. Preparing the defibrillator for operation, calculating the required dose of defibrillation discharge;
Analysis of heart rhythm disturbances according to ECG monitoring or ECG readings (work on a mannequin simulating heart rhythm disturbances);
Carrying out initial stage intensive therapy for cardiac arrhythmias;
Assessment of CO 2 monitoring indicators in exhaled air. Making a tactical decision based on the results of the data received;
Rules for communicating with the parents of a child in critical condition. Ways and means of eliminating conflict situations.
Thus, we propose to consider simulation technologies in teaching ordinary students not only as component clinical training, and moreover, as one of the mechanisms that trigger and form clinical thinking at a high and motivated level. Consequently, these forms of training require deterministic methodological support and control from leading educational and methodological associations, scientific evaluation and further research and improvement.
Reviewers:
Aydemirov A.N., Doctor of Medical Sciences, Professor, Head. surgical thoracic department, State Healthcare Institution "Stavropol Regional Clinical Center for Specialized Types of Medical Care", chief thoracic surgeon of the Stavropol Territory, Stavropol;
Karakov K.G., Doctor of Medical Sciences, Professor, Head. Department of Therapeutic Dentistry, Head of the Center for Practical Skills of the Faculty of Dentistry, Stavropol State Medical Academy of the Ministry of Health and Social Development of the Russian Federation, Stavropol
The work was received by the editor on September 23, 2011.
Bibliographic link
Muravyov K.A., Khojayan A.B., Roy S.V. SIMULATION TRAINING IN MEDICAL EDUCATION – A TURNING POINT // Fundamental Research. – 2011. – No. 10-3. – pp. 534-537;URL: http://fundamental-research.ru/ru/article/view?id=28909 (access date: 02/01/2020). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"
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The reasons for the lack of uniform methods of simulation training: the lack of complete and correct information in the country on the choice of a simulation system, the absence in the Russian Federation of a system for training specialists in simulation training, incomplete compliance of the software features of robotic simulators with national standards for training and providing care to patients.
Sorokin S.V.
Karl Storz Training Center
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The opening of a training center in Moscow is a gift for the Russian medical community. Over the course of several months of work, 500 medical workers, 350 doctors and 150 nurses passed through the walls of the training center, and 30 trainings were conducted in various surgical specialties.
Bjerrum Flemming
Modern approaches to laparoscopic simulation training
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Given the nature of the training program, the likelihood of a surgeon being a pilot's first passenger is much greater than the likelihood of a pilot being a surgeon's first patient.
Kossovich M.A.
Training in laparoscopic surgery in the system of postgraduate professional education of doctors
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Optimization of the learning process in laparoscopic surgery is one of the important methodological issues of modern surgery. Special educational centers, specialized departments and departments of research centers are called upon to solve this problem.
Marcus Lira
Realistic simulation in surgery
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Simulation training and accreditation in plastic, reconstructive and laparoscopic surgery. Realistic simulation: proctology, hysteroscopy, urology and hydrolaparoscopy. Transnasal neuroendoscopy and rhinosurgery – practical training
E.I. Brekhov, I.G. Repin, V.V. Kalinnikov, S.P. Mizin, M.V. Korobov
The use of simulation technologies in the process of training surgeons in clinical residency
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During the entire period of training in internship and residency, the doctor is prohibited from operating on patients or performing any invasive manipulations on patients. Practicing manual skills on corpses in the pathological anatomy department and in a vivarium on animals is also practically impossible
Gvozdevich V.D., Kozlov A.S., Kernesyuk N.L., Sysoeva L.F., Aliev R.Sh., Kyazimov V.A. Shanygin A.A.
Complex use of simulation simulators in mastering basic skills in operative surgery
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Model of teaching the discipline “operative surgery and topographic anatomy” at USMA (Ekaterinburg): modular teaching principle, point-rating system for assessing the knowledge of students, interns, residents, 100% computerization of training - e-books, interactive programs, computer testing, remote control educational process through the department’s website, final exam-computer testing, basic skills testing on a corpse, interview.
Andreas Pommert
Virtual simulator of ENT surgery and dentistry
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Training: temporal bone surgery (Tempo), endoscopic sinus interventions (Sinus), tooth preparation (Dental). Skill assessment: pre-assigned tasks, automatic assessment, recording. Ability to create your own tasks. The system cannot replace generally accepted teaching methods, but should be used at the initial stage of training. Possibility of realistic, reusable training. Positive test results
Khamatkhanova E.M.
Modern educational technologies in medicine: problems and prospects
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Advantages of studying in a specialized hospital: the process of advanced training of doctors is inextricably linked with an institution providing highly qualified medical care; training is carried out in conditions as close as possible to clinical ones; consolidation of the acquired practical skills continues in the specialized departments of the Center.
Panova I.A.
The role of the simulation and training center in training personnel in the field of obstetrics and neonatology
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The simulation and training center is intended for obstetricians-gynecologists, neonatologists, anesthesiologists-resuscitators, anesthesiologists-resuscitators working in obstetrics and gynecology medical organizations
Vasilyeva E.Yu.
Organization and accreditation of a simulation center at the Faculty of Medicine: the example of the University of Nice (France)
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Why do we need European experience or outsourcing? To develop the concept of simulation training in Russia. To save time, intellectual and financial resources in the process of creating simulation centers in medical education. To be equal in the competitive environment of medical education.
Joe Crofts
Outcome-based research in Obstetric simulation
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Simulated emergencies should be organized to improve management of rare obstetric emergencies
Chukichev A.V.
Experience in creating a training simulation center at the Chelyabinsk State Medical Academy
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Increasing the efficiency of mastering manual and therapeutic-tactical skills by introducing high-tech robotic mannequins and modern resuscitation equipment into the educational process in order to improve the quality of obstetrics and perinatal care
6. Ofordeme K.G., Papa L., Brennan D.F. Botfly myiasis: a case report. C.J.E.M. 2007; 9: 380-2.
7. Clyti E., Deligny C., Nacher M., del Giudice P., Sainte-Marie D., Pradinaud R. et al. An urban epidemic of human myiasis caused by Dermatobia hominis in French Guiana. Am. J. Trop. Med. Hyg. 2008; 79: 797-8.
8. Goksu T., Lonsdorf A., Jappe U., Junghanss T. Furunculoid skin lesions after travel to the tropics. Internist (Berl.). 2007; 48: 311-3.
9. Hu J.M., Wang C.C., Chao L.L., Lee C.S., Shin C.M., Telford S.R. First report of furuncular myiasis caused by the larva of botfly, Dermatobia hominis, in a Taiwanese traveler. Asian Pac. J. Trop. Biomed. 2013; 3: 229-31.
10. Sidelnikov Yu.H., RudikA.A. Dermatobiasis in Khabarovsk. Far East J of Infectious Pathology. 2008; 13: 169-72. (in Russian)
11. Clyti E., Pages F., Pradinaud R. Update on Dermatobia hominis: South American furuncular myiasis. Med. Trop. (Mars.). 2008; 68: 7-10.
12. M.R.L., Barreto N.A., Varella R.Q., Rodrigues G.H.S., Lewis D.A. et al. Penile myiasis: a case report. Sex. Transm. Infect. 2004; 80: 183-4.
13. Boruk M., Rosenfeld R.M., Alexis R. Human botfly infestation presenting as peri-auricular mass. Int. J. Pediatr. Otorhinolaryngol. 2006; 70: 335-8.
14. Denion E., Dalens P.H., Couppie P., Aznar C., Sainte-Marie D., Carme B. et al. External ophthalmomyiasis caused by Dermatobia hominis. A retrospective study of nine cases and a review of the literature. Acta Ophthalmol. Scand. 2004; 82: 576-84.
15. Rossi M.A., Zucoloto S. Fatal cerebral myiasis caused by the
tropical warble fly, Dermatobia hominis. Am. J. Trop. Med. Hyg. 1973; 22: 267-9.
16. Vijay K., Kalapos P., Makkar A., Engbrecht B., Agarwal A. Human botfly (Dermatobia hominis) larva in a child's scalp mimicking osteomyelitis. Emerg. Radiol. 2013; 20: 81-3.
17. Clyti E., Nacher M., Merrien L., El Guedj M., Roussel M., Sainte-Marie D., Couppie P. Myiasis owing to Dermatobia hominis in a HIV-infected subject: Treatment by topical ivermectin. Int. J. Dermatol. 2007; 46:52-4.
TEACHING ISSUES
I heard and forgot, I saw and remembered, I did and understood Confucius
I.I. Kosagovskaya, E.V. Volchkova, S.G. Pack
MODERN PROBLEMS OF SIMULATION TRAINING IN MEDICINE
1GBOU VPO First Moscow State Medical University named after. THEM. Sechenov Ministry of Health of Russia, 119991, Moscow, st. Trubetskaya, 8
Before using them on real patients, students must acquire practical skills in clinical work in special centers equipped with high-tech simulators and computerized mannequins that allow them to simulate clinical situations. One of the important prerequisites for the implementation of this principle is the creation of modern simulation centers. The article discusses the challenges that need to be addressed to successfully and effectively implement simulation learning in medical education. Keywords: simulation training in medicine; simulation technologies; simulation center; simulation training; simulation methods; formation of practical competencies.
I.1. Kosagovskaya1, E. V. Volchkova1, S. G. Pak1
CURRENT PROBLEMS OF THE SIMULATION-BASED EDUCATION IN MEDICINE
II.M. Sechenov First Moscow State Medical University, 8-2, Trubetskaya street, Moscow, Russian Federation, 119991
Practical skills of clinical work before applying them to real patients, students should acquire in special centers, equipped with high-tech simulators and computerized mannequins, permitting to simulate the clinical situations. One of the important prerequisites to the implementation of this principle is the creation of modern simulation centers. In the article there are discussed the problems which must be sold for the successful and effective implementation of a simulation training in the medical education.
Key words: simulation training in medicine; simulation technologies; simulation center; simulation training; simulation techniques; development of practical competencies.
The rapid development of high-tech medicine in the modern world places increased demands on the quality of medical services. The quality of medical care and the quality of life of patients should form the basis for assessing both the professional activities of individual specialists and institutions, and the level of healthcare as a whole. In the United States, there are 98 thousand deaths per year that occur due to medical errors. There are no such official statistics in the Russian Federation, but the problem of developing the practical competencies of a doctor is also quite acute. Thus, according to a survey of medical school graduates in 2012, only 12% of them rate their knowledge of practical skills as good. In addition, insufficient development of non-technical skills (including teamwork, leadership, effective communication, knowledge and the ability to make good decisions) are common causes of medical errors.
It is obvious that modern medical education must correspond to the ongoing technological revolution and changes in the surrounding information environment. High modern requirements for the development of practical skills by medical students, for updating educational material and bringing the educational environment closer to the new environment of practical healthcare make virtual technologies in medical education a key direction in the development of higher medical schools.
Relevance of the problem
The classical system of clinical medical education is not able to fully solve the problem of high-quality practical training of doctors. The main obstacles to this are the lack of continuous feedback between the student and the teacher, the impossibility of practical illustration of the entire variety of clinical situations, as well as moral, ethical and legal restrictions in the communication of students with the patient. Therefore, the key task of modern secondary, higher and postgraduate medical education is to create conditions for students to develop a wide range of competencies and firmly established practical skills without the risk of harm to the patient. This includes developing the ability to make quick decisions and flawlessly perform a series of manipulations or interventions, especially in emergency situations.
It is obvious that the training of specialists responsible for the life and health of people in the modern world simply cannot be built without the most important simulation component. A lot of experience has already been accumulated, proving the effectiveness of simulation training.
Numerous evidence has been obtained indicating the successful transfer of work skills acquired by a doctor to the treatment of a patient, which could not but lead to the extensive development of a network of simulation centers. Thus, over the 5 years from 2003 to 2008 in the United States, the number of residencies using simulation training for doctors increased sharply,
For correspondence: Kosagovskaya Irina Igorevna, Ph.D. honey. Sciences, Associate Professor of the department. of public health and preventive medicine of the First MPMU named after. THEM. Sechenov, e-mail: [email protected]
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specializing in emergency medicine. Thus, in 2003, simulation training existed in 33 (29%) residencies out of 134 respondents, and in 2008 - in 114 (85%).
The global trend of increasing the number of simulation centers has not left Russia aside. A circle of specialists in this field is being formed, international experience is being adapted to the peculiarities of domestic education. Several Russian specialized events with mixed participation have already taken place, where, in addition to solving the promotional tasks of conference organizers, there was an interested discussion of the truly important applied aspects of simulation training. Simulation techniques have firmly entered the medical education system and have become an integral part of training in healthcare. In the majority educational institutions new ones have appeared structural units- simulation and certification centers. Due to decentralized development, they all acquired a different organizational structure, specialization, equipment options, and work according to different methods and standards.
At the beginning of 2012, the Russian Society for Simulation Training in Medicine (ROSOMED) was created, in which enthusiasts and like-minded professionals in the field of training joined forces medical personnel without risk for the patient and doctor, using simulation technologies. During this short period of time, the ROSOMED society became a co-organizer of two major all-Russian conferences with international participation, experts from the society spoke at European and world congresses, joint developments of simulation equipment with leading global and domestic manufacturers were started and successfully implemented, a team of authors wrote the first domestic manual “Simulation training in medicine." In the spring of 2013, the Committee on Continuing Medical Education was created under the Ministry of Health of the Russian Federation. The first steps have been taken to develop domestic standards for simulation training, new classifications of equipment and simulation and certification centers have been proposed.
Research has been conducted to prove the need to increase the efficiency of training of medical personnel (see table), which can be achieved through the active introduction of simulation training into the process of continuous professional education.
About terminology
Currently, there are different definitions of the concept of “simulation learning”. If we talk
about this approach, regardless of professional activity, then most often simulation training is considered as a mandatory component in professional training, using a model of professional activity in order to provide each student with the opportunity to perform professional activity or its individual elements in accordance with professional standards and/or procedures (rules).
McPaghey (1999) describes a simulation as “a person, device, or set of conditions that allows an authentic recreation of a real-life problem. The student or trainee must respond to the situation as he or she would have done in real life.” real life" .
David Paba of Stanford University has proposed a more detailed definition of the term, according to which simulation is "a technique (not a technology) that replaces or enriches the learner's practical experience with an artificial situation that reflects and reproduces problems occurring in the real world." , in a completely interactive manner." Paba also argued for the need for planning in an organization educational process; he emphasized that simulation is primarily about learning, not about the technology behind the simulation.
Nicolas Marant and Ronnie Plavin from the Scottish Clinical Simulation Center described simulation as “an educational technique that provides an interactive, immersive activity by reproducing a real clinical situation in whole or in part, without the associated risk to the patient.”
Thus, simulation is an imitation, simulation, realistic reproduction of a process. And simulation in medical education is a modern technology for teaching and assessing practical skills, abilities and knowledge, based on realistic modeling, imitation of a clinical situation or a separate physiological system, for which biological, mechanical, electronic and virtual (computer) models can be used.
Simulation training should be conducted by specially trained full-time instructors (teachers-trainers, training masters), who, together with practicing specialists (experts), will create and accumulate various scenarios, conduct methodological work, and also, together with technical workers (technicians and engineers), develop and maintain training tools (software, computers, simulators, simulators, phantoms, models and professional equipment) in working and safe condition based on a system of engineering maintenance and supply of consumables.
One of the important stages of simulation training is debriefing.
Debriefing (from the English debriefing - discussion after completing a task) is the analysis that follows the execution of a simulation exercise, analysis of the “pros” and “cons” of the trainees’ actions and discussion of the experience they have acquired. This type of activity activates reflective thinking in students and provides feedback for evaluation
ki quality of performance of the simulation task and consolidation of acquired skills and knowledge. Research shows that learners have a limited understanding of what is happening to them when they are involved in a simulation experience. Being in the center of the action, they see only what can be seen from the point of view of an active participant. Therefore, it is thanks to debriefing that the simulation experience turns into conscious practice, which will ultimately help the trainee prepare both emotionally and physically for future professional activities.
According to S. Salvoldelli et al. Conducting a debriefing significantly increases the effectiveness of a simulation lesson on crisis situations in anesthesiology. Another study found that incorporating debriefing into simulation training for anesthesiologists increased the effectiveness of training as well as the retention of acquired knowledge and skills by trainees.
Forms and methods of medical simulation training
The history of the use of medical simulation in the training of doctors goes back many millennia and is inextricably linked with the development medical knowledge and the course of scientific and technological progress. Thus, the successes of the chemical industry led to the appearance of plastic mannequins, the progress of computer technology predetermined the creation of virtual simulators and patient simulators.
In the domestic healthcare system, among other things, various phantoms, models, dummies, simulators, virtual simulators and other technical training tools have appeared and are being widely introduced, allowing one to simulate processes, situations and other aspects of the professional activities of medical workers with varying degrees of reliability. At the same time, while individual phantoms for practicing simple practical skills have been used for a long time in some educational institutions, the introduction of complex virtual simulators and systems for managing their use in education appeared only in the last decade. To date, sufficient experience has been accumulated in the use of simulation methods in education, including medical education.
Doctors starting their practical work need a fairly long period to acquire practical skills in performing various medical interventions. So, according to different authors, doctors specializing in the field of endovideo-surgery need to perform from 10 to 200 laparoscopic cholecystectomies, 20-60 fundoplications, etc.
Traditional forms of teaching practical skills as a doctor include the following options: on animals, on cadavers, with the participation of patients (assisting during supervision and operations). All of these training options have significant disadvantages - when training on animals, it is necessary to maintain and maintain a vivarium, pay for the work of its employees, and purchase animals; At the same time, the number and time of performing manipulations is limited; constant individual supervision of the teacher is required. subjective assessment the student’s work, there are organizational problems with the use of drugs, it is necessary to take into account the protests of animal rights activists, ethical problems
etc. Training on cadavers is also difficult and inconvenient, which requires the organization of a special service, and the work is unrealistic.
To achieve the proper level of practical skills, it is necessary to perform 100-200 procedures under the supervision of a teacher. These training options require expensive equipment, tools and supplies. And finally, due to the danger of harm to the patient and the risk of developing iatrogenic complications, obtaining initial, basic practical skills with the participation of patients should be considered unacceptable.
The only effective and safe way to practice practical skills is currently provided by virtual technologies. Computer-simulated situations actively respond to the actions of cadets and completely imitate the patient’s physiological response to the doctor’s actions or reproduce an adequate tissue response to the surgeon’s manipulations. Doctors who have mastered practical skills using virtual simulators move on to real interventions much faster and more confidently, and their further real results become more professional. In addition, computer modeling based on objective data from a real patient (MRI, CT, ultrasound, etc.) allows you to predict in advance and even work out the upcoming study or operation, which reduces the potential risk and improves the quality of medical care.
Training on robotic patient simulators allows you to assess the initial level of teamwork and significantly increase it during the training process. In a study conducted on simulators to simulate traumatic shock, a significant increase in team skills was proven during the training process. At the same time, it is worth taking into account the data of the study, which proved that the mastery of CPR skills is higher on robotic simulators than on simulators.
Currently, dozens of companies around the world produce virtual simulators for many medical specialties. Dozens of annual conferences are devoted to them, and hundreds of articles are published. Virtual simulators have a number of undoubted advantages over the training options discussed above - there are no ongoing financial costs, the duration and mode of training are not limited in time, any number of repetitions of the exercise is possible with automatic, instant and impartial qualitative and quantitative assessment until its complete proven mastery is achieved and consolidation, the constant presence of a teacher is not required, methodological recommendations are carried out automatically, the program itself indicates errors made, and objective certification is carried out. Already the first studies carried out by N. Seymour, T. Grantcharov show the advantages of virtual simulators. According to the authors, the use of a virtual simulator in the educational process significantly, by 2.5 times, reduces the number of errors that novice surgeons make when performing their first laparoscopic operations. Research results support the continued implementation of virtual simulation technologies in medical education and training programs.
Realism of simulation equipment (fi-
delity), used for training health workers, is divided into seven levels. When developing simulators, each subsequent level is more difficult to implement. In accordance with these levels of realism, all simulators can be classified:
1. Visual, when traditional teaching technologies are used - diagrams, printed posters, models of the human anatomical structure. It can also be simple e-books and computer programs. The basis of any practical skill is visual simulation training, during which the correct sequence of actions when performing medical procedures is practiced. The disadvantage is the lack of practical training for the student.
2. Tactile, when the passive reaction of the phantom is reproduced. IN in this case manual skills, coordinated movements and their sequence are practiced. Thanks to realistic phantoms, you can bring individual manipulations to automation and acquire the technical skills to perform them.
3. Reactive, when the simplest active reactions of the phantom to the student’s actions are reproduced. Assessment of the accuracy of the actions of a trained person is carried out only at a basic level. Such mannequins and simulators are made of plastic and are supplemented with electronic controllers.
4. Automated - these are the mannequin’s reactions to external influences. Such simulators use computer technologies based on scripts, when a specific response is given by a phantom to certain actions. Cognitive skills and sensory motor skills are developed.
5. Equipment room - the environment of a medical office, operating room. Thanks to such training systems, a confident ability to act in a similar reality is achieved.
6. Interactive - complex interaction of the simulator mannequin with medical equipment and the cadet. Automatic change in the physiological state of an artificial patient, an adequate response to the administration of drugs, to incorrect actions. At this level, the trainee's qualifications can be directly assessed.
7. Integrated - interaction between simulators and medical devices. During the operation, virtual simulators demonstrate all the necessary indicators. psychomotor and sensorimotor skills of technical and non-technical skills are developed. The transition to the next level of realism will triple the cost of simulation equipment (the “triple” rule).
I would like to dwell separately on such a form of simulation training as the “standardized patient”. Standardized patient - a person (usually an actor) trained to simulate a disease or condition with high degree realism, so that even an experienced doctor will not be able to recognize the simulation. working with a “standardized patient” allows you to evaluate the skills of taking an anamnesis, compliance with deontological principles and assess the clinical thinking of the doctor.
The use of actors instead of patients during practical training was first tested in 1963 by teachers at the University of Southern California when teaching medical students as part of a three-year neurology training program. The role of patients was played by
actors trained to depict pathological conditions. A description of this experiment was published in 1964, but then, half a century ago, the method was considered expensive and unscientific. Then in 1968, the practice of using assistants to demonstrate gynecological examinations was introduced. More broadly, this covert integration of patient actors into clinical work occurred in the 1970s, with the rebranding of “patient-trainers” being changed to “standardized patients.”
The Medical Council of Canada introduced standardized patient assessment of medical students into its licensure program for the first time in 1993, and the following year this method of assessing knowledge and skills was formally adopted by the Educational Commission for Foreign Medical Graduates. Scientific research has proven the obvious effectiveness of simulation learning compared to traditional learning (Fig. 1).
The validity, reliability and practicality of the “practical clinical examination” have been confirmed and described in many studies, the data became the basis for the official approval by the National Board of Medical Examiners (NBME) of the practice of using standardized patients in courses IV-VII. The first mandatory testing of US medical students (Clinical Skills - Phase II) was performed in 2004 as part of the state licensure program. The practice of using a “standardized patient” also exists in the Russian medical education system, but it has not become widespread due to the high cost and difficulty of organization.
Speaking about modern simulation educational technologies, it seems necessary to separate the concept of technology for teaching practical skills and algorithms using specialized simulators and mannequins and the concept of simulation - clinical modeling of critical situations using specialized educational system, the main component of which is a multifunctional computerized mannequin simulating a real patient.
The first involves teaching a specific practical skill or even a group of skills, a technique or an algorithm using simulators or dummies of varying degrees of complexity. The main goal of such training is to teach a specialist to work with his hands, giving him the opportunity to perform specific practical manipulations, such as intubation, providing vascular access, defibrillation and many others. This concept also includes the practical development of individual techniques and algorithms, which becomes possible during practical work on dummies and allows the doctor to imagine in detail, organize and remember the necessary procedure in a critical situation. This individual training a specialist without being tied to his work in a team, which does not require recreating the realism of the patient, the place of emergency care or anesthesia, and the entire situation with the patient as a whole.
The second concept, simulation in emergency medicine, implies a broader context. The main objectives of simulation training are training to work with a patient in a critical situation in conditions as close as possible to those in which they usually
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Rice. 1. Results of a randomized anonymous clinical trial of the effectiveness of simulation training in the operating room.
a specialist is working. These conditions recreate the appearance of a real patient and his vital functions (from the ability to talk, breathe, reproduce pulsation in peripheral vessels, sounds, tones, murmurs of the heart, lungs, gastrointestinal tract to recording indicators on the monitors of real medical equipment). The computer program allows you to change patient parameters and create scenarios - clinically recreate various critical conditions that the trained specialist will learn to cope with using his knowledge, analytical abilities, clinical experience, practical skills, necessary medical equipment and personal characteristics. The main point of simulation training is the maximum imitation of all components that can be involved in a real life situation related to the treatment of a patient in a critical situation. The maximum reproduction of the place where the events take place should be ensured (this could be an operating room equipped with everything necessary, an intensive care ward with real beds and neighbors to the right and left, an ambulance equipped according to approved standards, etc.). Perhaps, if appropriate, a recreation psychological moments ongoing events that are achieved by involving “actors” - medical students, hospital staff or simply volunteers.
And, of course, to conduct simulation training, a team must be formed, in which the doctor will provide the necessary assistance. It must be remembered that one of the main objectives of simulation training is learning to work in a team with your colleagues. This allows you to learn how to quickly distribute roles and responsibilities, make your own decisions or unquestioning submission to a senior in the team and, ultimately, an effective and professional solution to the patient’s problem.
Methodological approaches to simulation training
For the effective use of simulation training, it is necessary to comply with the basic methodological and organizational principles:
1. Integration of simulation training into the current system of vocational education at all levels.
2. The presence of a legislative framework that contains the norm for admission to work (training) with patients, as well as a list of mandatory competencies in specialties that require the priority organization of simulation training. As a result, it should become the norm to exclude (exclude) from training (working) with patients persons who have not been certified using simulation techniques in accordance with the list of competencies in their specialty (level of education). The legislative framework should be flexible and improved as this area develops.
3. Intensive organization of the educational process, modular construction of the simulation training program and opportunities for simultaneous training of different categories of medical personnel (by type and specialty).
4. Objectivity of certification based on approved standards (rules), for compliance with criteria and with documentation and video recording of the process and results of pedagogical control, during which the influence of the examiner’s personality should tend to zero.
5. The presence of independent experts and observers during state certification procedures is mandatory from among employers (professional communities), as well as two members of societies associated with the protection of patients’ rights (changing each time).
6. A unified system for assessing the results of simulation training (for all organizers using these simulation techniques).
7. Availability of a system of state registration of the results of completion of the relevant modules of simulation training by specialists (registry of specialists).
8. Availability of a personnel training system (teachers, instructors) providing simulation training.
The pedagogical approach to creating a simulator has also become fundamentally new. The goal of simulation training is not only to master manual technical skills. The trainee must be aware of his presence in the medical environment, his inextricable connection with the patient being operated on, with his pathological condition. For this purpose, treatment cases are implemented in the form of tasks. The trainee is asked not only to perform technical actions, but also to assess the clinical situation and make the right tactical decision. The actions of the simulator operator do not just change virtual tissues, they worsen the condition of the virtual patient and provoke the development of complications in him, which will then have to be dealt with. This undoubtedly increases the realism of the simulation and the significance of such training in general.
There is a visual tool (Miller's pyramid, Fig. 2) for assessing the progress of a student (resident) - from beginner to expert. At the lowest level, the student has mastered knowledge that he can use to solve tests and in written or oral examinations. In the “know how” stage, they can use their knowledge in more complex exams that require the application of knowledge. In the "show how" stage, they can demonstrate their skills in simulated environments or in certification exams. But it is only in the “does” stage that they use their skills in real practice.
This simple model of the stages of clinical assessment
competence indicates that the analysis of clinical competence using simulation technologies is carried out at the stage “shows how (demonstrates)”, “does” and at the same time the performance or active participation in the implementation of a particular skill is assessed.
The introduction of monitoring the level of preparedness through a system of simulation training, a mandatory stage of certification in the conditions of simulation training of professional activities for each student and trainee, could help solve the problem of personnel certification. However, it is generally accepted that such monitoring should not be punitive in nature, but that the main efforts should be aimed at promoting professional development, identifying limitations and reducing the risks that an ill-prepared doctor or nurse may bear.
A standard training module or standard simulation module (SIM) is a unit of the educational process of simulation training, equal to three hours of working time of the training center, allocated for direct interaction of students with learning tools (practical training), accompanied by pedagogical supervision. Each such unit has a formulated final result of preparation and a certain cost. The presence of such a unit of the educational process will make it possible to calculate the needs for training specialists. SIM is necessary for organizing the educational process, and each of them includes a list of practical skills that will be developed (monitored) in students during this time.
The list of skills in the SIM should be combined on a thematic basis, according to the equipment involved and the achievability of training goals in 3 hours. In addition to clinical SIMs, it is necessary to develop SIMs for training new employees of simulation training centers and experts involved in this. SIMs can be implemented as stand-alone trainings and/or be part of a larger simulation training program.
SIM involves only practical training. To conduct training on one topic, several SIMs can be implemented in a row. Each SIM carried out in the form of training must necessarily have the following four parts:
1. Incoming control of the level of preparedness, instruction, setting goals and objectives of the training (up to 20% of the time);
2. Direct implementation of the educational task;
3. Debriefing, discussion of implementation;
4. Final execution (up to 10% of the time).
At least 70% of the time should be allocated to the second and third parts, and depending on the type of competencies, the distribution between them can range from 60:10 for individual skills to 30:40 for professional activities as a whole. The annotation for each SIM must indicate, in addition to the list of competencies, the maximum number of trainees in the group.
Currently, the mandatory requirement for simulation training and/or control is determined by:
For students, in the order of the Ministry of Health and Social Development of Russia dated January 15, 2007 No. 30 “On approval of the procedure for admitting students of higher and secondary medical educational institutions to participate in the provision of medical care to citizens,” which mentions
Clinical outcomes (individual) and rates (general population)
Action in real practice
Demonstration of preparedness (simulation, exam)
Interpretation, applied approach (description of action plan)
Theoretical knowledge (written exam)
Rice. 2. Miller's pyramid.
dummies (phantoms), but the volumes and rules for their use are not regulated in any way;
For interns and residents in the orders of the Ministry of Health and Social Development of Russia dated December 5, 2011 No. 1475n and No. 1476n “On approval of federal state requirements for the structure of the main professional educational program postgraduate professional education (residency, internship)" states that the training simulation course should be 108 academic hours (3 credits) for residents and 72 academic hours (2 credits) for interns;
The letter of the Ministry of Health and Social Development of Russia dated April 18, 2012 No. 16-2/10/2-3902 clarifies that preparation for postgraduate professional education programs in internship and residency in accordance with the above orders has been carried out since 2012/13, practice may be persons who have successfully mastered the disciplines of the educational program and completed the training simulation course are admitted.
Thus, it is legally established that the use of simulation training is mandatory for secondary, higher and postgraduate continuing medical education programs and must precede practice. Nevertheless, it is necessary to determine how this direction should function in order to properly use all its advantages.
Typology and organization of simulation centers
The operation of a simulation center depends on many factors. This is the presence of specialized premises designed to accommodate the existing set of equipment and future students, the organization of the learning process and management.
Some of these factors are determined by funding and are set by default. But many issues can be determined by the faculty, such as curricula and teaching structure. Here, a lot depends on the personal attitude of teachers towards simulation medicine. Currently, the issue of creating an innovative structural unit in the education system - a full-fledged simulation clinic - is being considered. It can be assumed that this is what is missing
Beginning
a link that ensures educational continuity between the preclinical and clinical stages of training. Essentially, the rough transition that existed between classroom teaching and clinical training is being smoothed out. This will undoubtedly reduce the stress that a novice doctor experiences when performing a particular technique at the patient’s bedside, and will have a positive effect on the quality of treatment.
Simulation techniques have firmly entered the medical education system and have become an integral part of training in healthcare. In most educational institutions, new structural units have appeared - simulation and certification centers. Due to decentralized development, they all acquired a different organizational structure, specialization, equipment options, and work according to different methods and standards.
To present the full variety of simulation training structures that exist today, they can be systematized according to a number of characteristics:
1. Sizes: from several rooms to multi-story detached educational buildings.
2. Geography: “metropolitan” simulation centers; federal, regional, district centers; small towns.
3. For medical specialties:
Specialized
training is conducted in one or more related disciplines, for example, in the specialty of anesthesiology, resuscitation, emergency care.
Multidisciplinary
Training is provided in various medical specialties.
Virtual clinic
organizational structure training center is similar to a multidisciplinary hospital, due to which it is possible to train medical teams of different specialties, conduct team trainings, and practice non-technical skills.
4. Level of skills mastered: basic; clinical skills, manipulation, surgery; high-tech interventions.
5. Contingent of trainees: students of a medical college or university; residents; doctors; drivers; employees of law enforcement agencies and the Ministry of Emergency Situations.
6. number of students: thousands of students - university, college; hundreds of cadets and residents - university, university, vocational training, professional education; dozens of doctors specialize in VMP.
7. Duration of study: years - university, residency; months - specialization; weeks and days - advanced training courses, short-term trainings.
8. Connection with practice:
Has a treatment base in the clinic;
It has an experimental operating room for conducting educational and research operations on biological models - a vivarium;
Has training classes at the Bureau of Forensic Medicine, hospital morgue, and the Department of Pathological Anatomy;
Does not have a clinical/experimental unit.
9. Placement:
Educational institution (university, university department, medical faculty of a classical university or medical college) - centers of practical skills and abilities at medical educational institutions.
Medical organization. Hospital training centers for managing the quality of medical care, ensuring high professionalism of doctors and nursing staff, improving and retraining staff of health care facilities
Manufacturer. Corporate training centers of the manufacturing company - for training employees and clients to work with the company’s equipment/tools/pharmaceuticals.
Industry. Mastering medical practical skills for applied industry purposes, for example, for training sailors, oil workers, cash collectors, employees of the Ministry of Emergency Situations, the Ministry of Internal Affairs, security companies, etc.
Mobile training centers mounted on vehicles or using portable autonomous simulation devices. Mobility allows you to bring simulation training closer to the user, to conduct training in the workplace (in situ) - in the operating room, intensive care unit, at the scene of a traffic accident, etc.
10. Personnel composition: differences between training centers in terms of the availability of academic degrees of the teaching staff, the qualifications of teachers in the field of simulation training, and the training they have completed in their specialty.
11. Form of ownership:
State. The purpose of creating state simulation centers is to increase the level of practical skills of students and doctors in the interests of the whole society.
Commercial training centers. The goal is to make a profit by selling simulation training services. Short-term, intensive, but most often expensive training courses. They can be organized on the basis of state university or hospital training centers on a rental basis or on partnership terms.
Corporate training centers are a type of private ones, so their goal is similar - to make a profit. It is achieved indirectly by increasing demand for the company’s products from educated consumers. Due to the high cost, courses are subsidized by the manufacturer or provided to clients free of charge.
Public-private partnership. The combination of founders leads to a mixture of goals, but in the short term they coincide - training doctors. Ultimately, both sides benefit: the state improves the qualifications of healthcare workers, and the company receives qualified consumers of their products.
Thus, there are currently dozens of different simulation centers operating in Russia, significantly different from each other in dozens of characteristics. At the same time, there is no single classification - simple, understandable, but at the same time structured, meeting the practical tasks of medical education. It should provide starting points for making decisions about the need to open a center, the choice of type, specialization, equipment and staffing of the center, the exact
setting objectives and drawing up curricula, approving methods and empowering.
It is proposed to divide simulation and certification centers into three levels:
Level I - basic, regional significance;
Level II - leading, district significance;
Level III - the highest, federal level.
When dividing centers into levels, some of the above criteria are considered basic, or primary, and the rest are considered secondary, logically arising from the first.
The main criteria include:
The quality of the educational process, which is indirectly characterized by the qualifications of teachers, the equipment of the center, the innovation and effectiveness of the methods used.
Own methodological developments
Conducting research, testing of medical equipment and other scientific work by the center’s staff.
The number of publications regarding methodological and scientific developments in domestic and foreign literature and their citation rate.
Active participation of center employees in specialized conferences.
Professionalism of the center's staff - work experience, previously completed trainings and current activities to improve the skills of employees, existing certificates and accreditations of the center and its individual employees.
The remaining criteria are important as a whole, but, in fact, each of them individually is not decisive. Even a large metropolitan center, generously equipped with the latest equipment, with weak management and low qualifications of staff, can have a low workload and a deservedly low reputation. The features of the centers of each of the three levels are described in more detail below.
Level I simulation centers:
Simulation centers of the I, regional (basic) level have the following characteristics:
Located at large hospitals, many universities and medical colleges.
They provide simulation training and certification for university (college) students, residents, or doctors from the region in which the center is located.
Trainings can be conducted both in different specialties and in one narrow specialty. The training program is mainly focused on mastering basic skills.
The centers are relatively small, occupying several rooms with a total area of up to 300 m2.
They have a variety of simulation equipment of levels I-VI (phantoms, simulators, single virtual simulators).
The budget for equipping with simulation equipment does not exceed 30 million rubles.
The staffing table of the centers includes up to 5 units: director, secretary-administrator, instructors, engineer. Training sessions can be conducted with the participation of department teachers or leading specialists from medical institutions
Center staff can develop new simulation training methods, but do not have the authority to test or officially approve them.
Level II simulation centers:
Simulation centers II, district level are characterized by the following:
In them, university students, residents and doctors from all over the federal district in which the center is located learn practical skills and their certification, and users learn new medical equipment.
The Centers conduct training in both different specialties and one at a time. It may also be a highly specialized center that provides educational services in one type of high-tech medical care (for example, transplantology, minimally invasive cardiac surgery and angiography, etc.).
They are located on the basis of leading universities and research institutes, with premises with a total area of 500 to 2000 m2.
The centers have a variety of simulation equipment of 1-UP levels of realism (phantoms, simulators, virtual simulators, up to complex virtual training systems).
Centers may have their own experimental operating room (vivarium).
The total cost of equipping with simulation equipment reaches 150 million rubles, but cannot be less than 25 million rubles.
The center schedule has from 3 to 10 staffing units: center manager, secretary-administrator, instructors, IT specialist, service engineer.
Many lectures and practical training sessions are conducted with the participation of department teachers or medical specialists, including from other cities and countries.
Center employees are required to improve their skills by participating in conferences, trainings and master classes.
Employees of the centers not only develop new methods of simulation training, but also have the right to test third-party methods.
Methodological and scientific developments should be cited in specialized literature.
Level III simulation centers:
Simulation centers III, federal level have the highest status and can be characterized by the following:
In addition to students and residents, a significant part of the educational process is aimed at improving the qualifications of doctors and their certification, as well as training teachers of simulation centers of levels I and II (TTT programs - Tgat-^e-Tgater). The geography of the students is the entire Russian Federation, as well as cadets from near and far abroad.
New medical equipment is being tested using simulation technologies - on virtual simulators or robots, and users are being trained in the principles of operating the new equipment.
At the highest level centers there are Scientific research on simulation technologies.
The centers represent most specialties, including narrow ones, and provide training in high-tech types of medical care.
The centers are located on the basis of parent, leading universities and clinical research institutions; they are large educational structures, occupying separate floors or buildings with a total area of 1000 m2.
Equipped with simulation equipment of all VII levels, including complex virtual training systems.
The center includes a “Virtual Clinic”, which allows you to practice the processes of interaction between doctors
whose various specialties and departments at all stages of patient treatment - from admission to the emergency room, diagnosis and surgical intervention to transfer from intensive care to the general ward and final discharge.
In our own experimental operating room (vivarium), the intervention skills acquired on simulators are consolidated and scientific and practical experiments are conducted.
The total cost of equipping the center with simulation equipment exceeds 150 million rubles and can reach up to 500 million rubles.
The staffing table of the Federal Centers includes at least 5 employees and their number can reach 20: the head of the center, his deputy, secretary-administrator, instructors, IT specialists, service engineers.
In addition, teachers from specialized departments, domestic and foreign lecturers are involved.
The center’s employees must, following principles similar to CME, improve their qualifications on an ongoing basis, annually participating in specialized conferences, seminars, trainings and master classes.
At the Level III center, new methods of simulation training are being developed, which should be cited in domestic and, preferably, foreign literature.
The center not only tests third-party methods, but is also authorized to approve them.
Thus, only centers of the third, highest, level based on a set of basic criteria should receive the right not only to develop new methods, but also to test and approve third-party developments; not only engage in the educational process, but actively lead scientific work and testing of medical equipment; not only train cadets, but also conduct training for teachers of level I and II simulation centers (TTT programs). And, on the other hand, a large center, with a large staff, equipped to the highest class, but at the same time not conducting active educational and scientific-methodological activities cannot, in the author’s opinion, claim the status of a “federal”, level III center.
Problems of practical implementation of simulation training
The accumulated experience of simulation training in the Russian Federation allows us, first of all, to be convinced of the undeniable advantages of simulation training:
Clinical experience in a virtual environment without risk to the patient;
Objective assessment of the achieved level of skill;
Unlimited number of skill repetitions;
Training at a convenient time, regardless of the clinic’s work;
Practicing actions for rare and life-threatening pathologies;
Transferring part of the teacher’s functions to a virtual simulator;
Increasing the efficiency of training medical specialists in new high-tech techniques, as well as new procedures within the framework of already practiced techniques;
Reducing stress during the first independent manipulations.
Thus, the virtual simulator, of course, does not replace traditional forms of training - lectures.
tion, seminar, watching videos and multimedia materials, supervision of patients, etc., however, before allowing a doctor to see a patient, it is necessary to practice practical skills on the simulator and certify the acquired skills. The above is confirmed by studies of foreign colleagues, which show that specialists highly value the opportunity to participate in simulation training. Despite the feeling of tension and sometimes real stress when working with such a “severe patient,” they prefer to see the immediate results of the treatment performed, rather than just read about them in textbooks or listen to lectures. Most of all, as the survey shows, specialists value the opportunity to make mistakes and learn from them in a safe educational environment.
In teaching the discipline “Infectious Diseases,” the use of simulation technologies has its own characteristics, related both to the specific clinical course of infectious diseases and to the knowledge and skills of senior students in basic theoretical and clinical training modules. The choice of forms of simulation training should be aimed at developing high level clinical competence in the diagnosis and treatment of infectious diseases, which must be integrated with communication and teamwork skills. This will allow you to effectively apply the acquired clinical competence in the specific practical activities of the doctor.
Before using them in working with real patients, students must acquire clinical work skills in special centers equipped with high-tech simulators and computerized mannequins that allow them to simulate certain clinical situations, including infectious diseases. In training centers, the content of training is aimed not only at mastering individual skills, but also at interdisciplinary training in teamwork, developing safe forms of professional behavior and communication skills with patients. But this requires the creation of such modern simulation centers, possibly within the framework of a clinical and educational cluster.
Another form of simulation training in the field of teaching infectious diseases, no less difficult for practical implementation, can be “standardized patients”, which are a better alternative to real patients. they can perform the role of the patient as standard, including psychological and physiological aspects. Volunteers, laboratory staff, teachers themselves, interns and others can be trained as standardized patients. Analysis of a simulated clinical case also involves working in a team, which allows students to jointly plan work, distribute responsibilities, assist each other, collaborate, interact in a group, discuss, understand and accept each other’s point of view or defend their own at each stage - interpretation of the analysis, making a diagnosis and prescribing treatment.
There is already an understanding of the need for simulation medicine, equipment is being purchased, simulation centers are opening, but the main thing is not yet available - standards for simulation training. Now everyone
The simulation center operates according to its own program. Programs have been written for clinical residency, resuscitators and non-resuscitation specialties, and paramedics. In universities, there is variation in approaches to teaching, methods, structure of classes, and assessment methods. This is due both to the capabilities and traditions of a particular department. It seems relevant to standardize simulation medicine teaching programs. Given the importance of the problem, it is necessary to take into account the enormous experience of foreign clinics and professional organizations when developing Russian standards. The creation of expert groups by specialty will make it possible to systematize the writing of recommendations.
At the same time, problems that need to be solved for the successful and effective implementation of simulation training in medical education are identified:
Creation of the concept of simulation training in the medical education system in the Russian Federation;
Creation of a normative and regulatory framework for simulation training;
Development and implementation of educational, methodological and software and tools for the simulation educational process;
Preparation teaching staff for simulation training;
Financial support for the simulation training system;
Conducting research projects to study the effectiveness of simulation training.
Due to the involvement of a large number of university specialists in the implementation of simulation training, the overall level of readiness of employees to implement virtual technologies in pedagogical process, thinking in general is modernized, teachers’ pedagogical approaches are improved and enriched.
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Volchkova Elena Vasilievna, Doctor of Medicine. Sciences, prof., head. department Infectious Diseases of the First Moscow State Medical University named after. THEM. Sechenov; Pak Sergey Grigorievich, doctor of medicine. Sciences, prof., corresponding member. RAMS, honorary head. department Infectious Diseases of the First Moscow State Medical University named after. THEM. Sechenov.
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