Recommendations and Guidelines for the Use of Simulation to Address Structural Racism and Implicit Bias

A national pilot study on simulation-based upstander training for emergency medicine clinicians

Objective

This study assesses the effectiveness of clinical simulation-based training in boosting self-perceived confidence for using upstander communication skills to confront racism, discrimination, and microaggressions (RDM).

Methods

We conducted an observational cohort study with emergency medicine professionals at the 2023 Scientific Assembly of the American Academy of Emergency Medicine in New Orleans, Louisiana. The study featured a clinical simulation-based training on upstander communications skills session followed by small- and large-group debriefs. Participants completed pre- and post-training questionnaires assessing demographics and confidence in health equity competencies. This survey was used in a previous study with emergency medicine residents. Data were analyzed using an independent Student's t-test, with a significance threshold of 0.05.

Results

Thirty-two individuals participated in the simulation-based training, and 24 completed surveys, with a 75% response rate. Most participants were non-Hispanic (24, 85.7%) and women (18, 64%), with racial demographics mostly White (8, 28.6%), Black or African American (8, 28.6%), and Asian (6, 21.4%). After the workshop, there was a notable increase in self-perceived ability and confidence in identifying RDM (from 7 ± 3.2 to 8.6 ± 1.6, p < 0.003), using upstander communication tools (from 6.1 ± 3.5 to 8.5 ± 1, p < 0.0001), and the likelihood of intervening in RDM situations (from 7.1 ± 3.3 to 8.8 ± 1.1, p < 0.0002).

Conclusions

The clinical simulation-based training significantly improved participants' confidence and self-perceived ability to address RDM in simulated clinical environments. This training method is a promising tool for teaching health equity topics in clinical medicine.

Addressing Culturally Based Hidden Bias and RacisM (A-CHARM) Using Simulation Experiences, Nik's Story: A Quasi-Experimental Study

BACKGROUND/PURPOSE

Racism and hidden bias experienced by underrepresented nursing students contribute to a loss of confidence and anxiety. The A-CHARM nursing project developed virtual simulation experiences for nursing students to practice how to address racism. 'Nik's Story' virtual simulation was created as part of the A-CHARM project. The purpose of this study was to examine the effectiveness of an education intervention, that included Nik's story, on cultural humility and cultural diversity awareness.

METHOD

This quasi-experimental study included a convenience sample of final year nursing students. After informed consent, participants completed a pre-intervention questionnaire that included the Cultural Humility Scale "context for difference in perspective" subscale, and the Cultural Diversity Awareness questionnaire to assess baseline knowledge. Students participated in an education intervention that included a lecture, Nik's story virtual simulation experience, a debrief and then completed a post-education/simulation questionnaire that included usability/learner engagement questions and the Cultural Humility Scale "context for difference in perspective" subscale, and the Cultural Diversity Awareness questionnaire.

RESULTS

Forty-seven students consented and completed the pre/post intervention questionnaire. Participants rated the effectiveness, engagement and usability of the simulation experience highly. There was a significant positive change in cultural humility "context for difference in perspective" subscale (pre-scores = 6.9, SD = 3.3; post-scores = 31.0, SD = 3.8, p < 0.001), and cultural diversity awareness (pre-scores = 95.4, SD = 8.9; post-scores = 103.4, SD = 9.8, p < 0.001).

DISCUSSION

This intervention was effective in improving cultural humility and cultural diversity awareness in nursing students.

CONCLUSION

Simulation experiences regarding racism in the clinical setting provide a strategy for students to learn how to professionally navigate unwanted experiences.

Development and evaluation of a clinical simulation-based educational innovation on sexual orientation and gender identity in emergency medicine

INTRODUCTION

Sexual orientation and gender identity (SOGI)-diverse patients are marginalized and poorly cared for in the emergency department, yet well-designed educational interventions to meet this gap are lacking. We developed, implemented, and assessed a novel multi-modal SOGI curriculum on health and cultural humility for emergency medicine physician trainees.

METHODS

We conducted a prospective, single-arm evaluation of our educational intervention. A convenience sample of emergency medicine resident physicians (n = 21) participated in the facilitated curriculum including didactic and clinical simulation components. Participants completed a pre- and post-curriculum evaluation that assessed clinical skills, preparedness, attitudinal awareness, and basic knowledge in caring for SOGI-diverse patients. The content of the module was based on a scoping literature review and national needs assessment of Canadian emergency physicians, educators, and trainees along with expert collaborator and input from patient/community partners. The curriculum included a facilitated pre-brief, didactic presentation, clinical simulation modules, and a structured de-brief. Participant clinical skills were evaluated before and after the educational intervention. Our primary outcome was change in clinical preparedness, attitudinal awareness, and basic knowledge in caring for SOGI-diverse patients pre- and post-intervention.

RESULTS

Our patient-centered, targeted emergency medicine SOGI health and cultural humility training resulted in a significant improvement in resident self-rated clinical preparedness, attitudes, and knowledge in caring for SOGI-diverse patients. This training was valued by participants.

CONCLUSION

We have designed an effective, patient-centered curriculum in health and cultural humility for SOGI-diverse patients in EM. Other programs can consider using this model and developed resources in their jurisdictions to enhance provider capacities to care for this marginalized group.

Inclusivity in health professional education: how can virtual simulation foster attitudes of inclusion?

Disparities in accessing quality healthcare persist among diverse populations. Health professional education should therefore promote more diversity in the health workforce, by fostering attitudes of inclusion. This paper outlines the potential of virtual simulation (VS), as one method in a system of health professional education, to promote inclusion and diversity. We conceptualise how VS can allow learners to experience an alternative to what HPE currently is by drawing on two social justice theorists, Paulo Freire, and Nancy Fraser and their ideas about 'voice' and 'representation'. We present two principles for VS design and implementation: (1) giving voice to learners has the power to transform; and (2) representation in VS builds inclusion. We provide practical means of building voice and representation into VS learning activities, followed by an example. Purposeful and thoughtful integration of these principles paves the way for a more diverse and inclusive healthcare workforce.

A Modified Delphi Study for Curricular Content of Simulation-Based Medical Education for Pediatric Residency Programs

OBJECTIVE

We sought to establish core knowledge topics and skills that are important to teach pediatric residents using simulation-based medical education (SBME).

METHODS

We conducted a modified Delphi process with experts in pediatric SBME. Content items were adapted from the American Board of Pediatrics certifying exam content and curricular components from pediatric entrustable professional activities (EPAs). In round 1, participants rated 158 items using a four-point Likert scale of importance to teach through simulation in pediatric residency. A priori, we defined consensus for item inclusion as ≥70% rated the item as extremely important and exclusion as ≥70% rated the item not important. Criteria for stopping the process included reaching consensus to include and/or exclude all items, with a maximum of three rounds.

RESULTS

A total of 59 participants, representing 46 programs and 25 states participated in the study. Response rates for the three rounds were 92%, 86% and 90%, respectively. The final list includes 112 curricular content items deemed by our experts as important to teach through simulation in pediatric residency. Seventeen procedures were included. Nine of the seventeen EPAs had at least one content item that experts considered important to teach through simulation as compared to other modalities.

CONCLUSIONS

Using consensus methodology, we identified the curricular items important to teach pediatric residents using SBME. Next steps are to design a simulation curriculum to encompass this content.

Moving towards deep equity, diversity, inclusivity and accessibility in simulation: a call to explore the promises and perils

Principles and issues of equity, diversity, inclusivity, and accessibility (EDIA) are being explored currently in simulation designs and trainings but with limited depth, often raising more questions than answers. This editorial invites the broader healthcare simulation community to move beyond the superficial to explore more expansively and deeply these issues of EDIA within simulation. Simulation is the very environment and context from which we may confront how existing (power) structures can be dismantled and re-envisioned for more optimal redistribution of participation, power, and benefits. We can use simulation to experiment with variations of these realities, and start exploring consequences of such alternatives to benefit our broader health systems and societies. Simulation uniquely combines opportunities for experience, reflection, application and active experimentation, enabling a ripe ground for this study. In fact, it is the responsibility of simulation educators to take up this challenge, and to engage in meaningful scholarship to understand more about the impact of simulation in exploring EDIA topics. This editorial invites contributions of empirical and theoretical works that advance our collective understanding of EDIA, while also cautioning against complacency. The simulation community is urged to look inwards and also examine its own practices critically, in spite of the uncertainty, vulnerability and risks that this presents.

Disparities in outcomes and access to therapy options in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) disproportionately impacts racial and ethnic minorities and patients with lower socioeconomic status. These social determinants of health (SDH) lead to disparities in access to care and outcomes. We aim to understand the relationship between SDH and survival and locoregional treatment options in HCC.

METHODS

Using the National Cancer Database, we evaluated survival and access locoregional treatments including non-transplant surgery, liver transplant (LT), and liver-directed radiation therapy (LDRT) in patients with HCC diagnosed between 2004 and 2017. Variables including clinical stage, age, sex, race, income, rurality, year of diagnosis, facility type (FT), Charlson-Deyo score (CD), and insurance were evaluated. Cox proportional hazards multivariable regression and dominance analyses were used for analyses.

RESULTS

In total, 140 340 patients were included. Worse survival was seen with advanced stage, older age, Black race, rurality, public insurance, treatment at a nonacademic center, and lower income. The top predictors for survival included stage, age, and income. Completion of non-transplant surgery was best predicted by stage, FT, and insurance type, whereas LT was predicted by age, year of diagnosis, and CD score. LDRT utilization was most associated with year of diagnosis, FT, and CD score.

CONCLUSION

For patients with HCC, survival was predicted primarily by stage, age, and income. The primary sociodemographic factors associated with access to surgical treatments, in addition to FT, were insurance and income, highlighting the financial burdens of health care. Work is needed to address disparities in access to care, including improved insurance access, addressing financial inequities and financial toxicities of treatments, and equalizing care opportunities in community centers.

Structural Competency in Simulation-Based Health Professions Education: A Call to Action and Pragmatic Guide

SUMMARY STATEMENT

Simulation-based health professions educators can advance diversity, equity, and inclusion by cultivating structural competency, which is the trained ability to discern inequity not only at an individual level, but also at organizational, community, and societal levels. This commentary introduces Metzl and Hansen's Five-Step Model for structural competency and discusses its unique applicability to the metacognitive underpinnings of simulation-based health professions education. We offer a pragmatic guide for simulation-based health professions educators to collaboratively design learning objectives, simulation cases, character sketches, and debriefs in which structural competency is a simulation performance domain, alongside patient management, resource usage, leadership, situational awareness, teamwork, and/or communication. Our overall goal is to promote a paradigm shift in which educators are empowered to partner with patients, colleagues, and communities to recognize, learn about, and challenge the factors driving health inequities; a skill that may be applied to a broad range of health professions education within and outside of simulation.

Analysis of Inclusive Gender, Sexuality and Sexual Orientation Data Elements in Academic Electronic Health Records

Findings from an analysis of three vended academic electronic health records used in health science education are presented in this article. The quality assurance project examined the lexical and semantic fit and content coverage of gender, sexuality, and sexual orientation data elements within the academic electronic health records. A semantic comparative content analysis using a cognitive walkthrough was conducted as a means of comparing the ideal set of gender, sexuality, and sexual orientation data elements with those found in the three vended academic electronic health records. The results indicated a need for alignment to the research literature, expert consensus, and technical standards similar to what is expected for electronic health records used in clinical practice because of a lack of ideal state data elements. The findings align with ongoing issues with bias and disparities seen in the care of the lesbian, gay, bisexual, and transgender population and a lack of diverse, inclusive media and teaching technologies in health science education. The quality project and findings can inform academic electronic health record vendors on how they can create more inclusive systems and bring awareness to healthcare educators about the potential for implicit and explicit bias in their teaching technologies.

Race and Ethnicity and Primary Language in Emergency Department Triage

Importance

Emergency department (ED) triage substantially affects how long patients wait for care but triage scoring relies on few objective criteria. Prior studies suggest that Black and Hispanic patients receive unequal triage scores, paralleled by disparities in the depth of physician evaluations.

Objectives

To examine whether racial disparities in triage scores and physician evaluations are present across a multicenter network of academic and community hospitals and evaluate whether patients who do not speak English face similar disparities.

Design, Setting, and Participants

This was a cross-sectional, multicenter study examining adults presenting between February 28, 2019, and January 1, 2023, across the Mass General Brigham Integrated Health Care System, encompassing 7 EDs: 2 urban academic hospitals and 5 community hospitals. Analysis included all patients presenting with 1 of 5 common chief symptoms.

Exposures

Emergency department nurse-led triage and physician evaluation.

Main Outcomes and Measures

Average Triage Emergency Severity Index [ESI] score and average visit work relative value units [wRVUs] were compared across symptoms and between individual minority racial and ethnic groups and White patients.

Results

There were 249 829 visits (149 861 female [60%], American Indian or Alaska Native 0.2%, Asian 3.3%, Black 11.8%, Hispanic 18.8%, Native Hawaiian or Other Pacific Islander <0.1%, White 60.8%, and patients identifying as Other race or ethnicity 5.1%). Median age was 48 (IQR, 29-66) years. White patients had more acute ESI scores than Hispanic or Other patients across all symptoms (eg, chest pain: Hispanic, 2.68 [95% CI, 2.67-2.69]; White, 2.55 [95% CI, 2.55-2.56]; Other, 2.66 [95% CI, 2.64-2.68]; P < .001) and Black patients across most symptoms (nausea/vomiting: Black, 2.97 [95% CI, 2.96-2.99]; White: 2.90 [95% CI, 2.89-2.91]; P < .001). These differences were reversed for wRVUs (chest pain: Black, 4.32 [95% CI, 4.25-4.39]; Hispanic, 4.13 [95% CI, 4.08-4.18]; White 3.55 [95% CI, 3.52-3.58]; Other 3.96 [95% CI, 3.84-4.08]; P < .001). Similar patterns were seen for patients whose primary language was not English.

Conclusions and Relevance

In this cross-sectional study, patients who identified as Black, Hispanic, and Other race and ethnicity were assigned less acute ESI scores than their White peers despite having received more involved physician workups, suggesting some degree of mistriage. Clinical decision support systems might reduce these disparities but would require careful calibration to avoid replicating bias.

Using Simulation to Teach Learners in Health Care Behavioral Skills Related to Diversity, Equity, and Inclusion: A Scoping Review

SUMMARY STATEMENT

Bias is commonplace in the health care environment and can negatively impact patients and their health outcomes. Simulation has long been shown to be an effective teaching tool for communication skills in health care, but it has rarely been used to deliver concrete behavioral skills that address issues of diversity, equity, and inclusion (DEI). This scoping review examines 23 published articles surrounding the use of simulation in health care education to impart behavioral skills that reduce bias and promote DEI. Included articles described various behavioral skills including communication, history-taking, and system/community-level advocacy. The most commonly used simulation modality to teach these skills included the use of simulated participants (16 articles, 70%). The main DEI topics addressed in the trainings included sexual orientation/gender identity, language, and culture/ethnicity. Based on findings from this review, the authors suggest recommendations for educators who are considering teaching DEI-related skills through simulation.

Implicit Bias and Patient Care: Mitigating Bias, Preventing Harm

Introduction

Simulation is a valuable and novel tool in the expanding approach to racism and bias education for medical practitioners. We present a simulation case focused on identifying and addressing the implicit bias of a consultant to teach bias mitigation skills and limit harm to patients and families.

Methods

Learners were presented with a case of a classic toddler's fracture in an African American child. The learners interacted with an orthopedic resident who insisted on child welfare involvement, with nonspecific and increasingly biased concerns about the child/family. The learners were expected to identify that this case was not concerning for nonaccidental trauma and that the orthopedic resident was demonstrating bias. They were expected to communicate with both the resident and the parent effectively to defuse the situation and prevent harm from reaching the family. A debrief and an anonymous survey followed the case.

Results

Seventy-five learners participated, including pediatric and emergency medicine residents, fellows, attendings, and medical students. After the case, the majority of learners expressed confidence that they could recognize racial bias in the care of a patient (90%), ensure patient care was not influenced by racial bias (88%), and utilize a tool to frame a concern about bias (79%).

Discussion

Participants felt that this simulation was relevant and effective and overall left the experience feeling confident in their abilities to identify and manage racially biased patient care. This anti-racist simulation offers an important skill-building opportunity that has been well received by learners.

Antiracism: An Ethical Imperative

Pediatric ethicists hold a privileged position of influence within health care institutions. Such a position confers a corresponding responsibility to address barriers to the health and flourishing of all children. A major barrier to children's health is racism. Pediatric ethicists can, and should, leverage their position to address racism both in institutional policy and the provision of pediatric care. Health care's historical and continued contributions to fostering and sustaining racist values and systems mean that those within all medical fields- regardless of race, ethnicity, gender, age, or profession-should consider ways they can work to offset and ultimately dismantle those values and systems. Institutional policy is a critical mechanism propagating racism in hospitals and an area where ethicists have a unique perspective to bring antiracism into ethical analysis. Many institutional and organizational policies have unintended consequences, negatively impacting children and families who have been historically marginalized and oppressed. In this paper, we report and discuss existing policies, along with how they are implemented (procedures) and how they are conducted (practices), identified through a workshop during a pediatric subgroup meeting at an annual bioethics conference. We highlight the need to focus on these structural factors and reference scholarship that can be used to correct institutional policies that uphold white supremacy. We conclude with actionable, concrete recommendations for change.

2022 consensus conference on diversity, equity, and inclusion: Developing an emergency medicine research agenda for addressing racism through health care research

Racism in emergency medicine (EM) health care research is pervasive but often underrecognized. To understand the current state of research on racism in EM health care research, we developed a consensus working group on this topic, which concluded a year of work with a consensus-building session as part of the overall Society for Academic Emergency Medicine (SAEM) consensus conference on diversity, equity, and inclusion: "Developing a Research Agenda for Addressing Racism in Emergency Medicine," held on May 10, 2022. In this article, we report the development, details of preconference methods and preliminary results, and the final consensus of the Healthcare Research Working Group. Preconference work based on literature review and expert opinion identified 13 potential priority research questions that were refined through an iterative process to a list of 10. During the conference, the subgroup used consensus methodology and a "consensus dollar" (contingent valuation) approach to prioritize research questions. The subgroup identified three research gaps: remedies for racial bias and systematic racism, biases and heuristics in clinical care, and racism in study design, and we derived a list of six high-priority research questions for our specialty.

Interprofessional Simulation as an Educational Tool to Assess Cultural Competence Among Health Professions Students

BACKGROUND

The concept of collaborative practice within health professions is viewed as "best practice." Poor collaboration can adversely affect patient safety. Interprofessional (IP) teamwork skills can be developed and nurtured through the health professionals' education; however, many barriers exist, which deter this from occurring. A lack of cultural diversity exposure within the healthcare setting can result in treatment disparities and place the patient at risk. One healthcare area that has gained considerable interest is the practitioners' understanding of multiculturalism and how cultural competence subsequently influences health disparities.

OBJECTIVES

This study examined the application of culturally complex clinical simulation scenarios that intentionally integrated IP teamwork and hypothesized that participants' understanding of cultural competence would improve.

METHODS

Participants were junior-level nursing, bachelor-level social work, graduate-level occupational therapy, and PharmD students (N = 180) who participated in an IP simulation exercise composed of culturally complex clinical scenarios performed by trained standardized patients designed to demonstrate underrepresented populations with diverse religious/spiritual, sexual orientation, racial/ethnic, socioeconomic, psychosocial, and geographic characteristics. Survey tools included an adapted Multicultural Awareness, Knowledge, and Skills Survey (MAKSS) and the Cultural Awareness Assessment Tool (CAAT). Descriptive statistical analyses were conducted to describe the sample population with the use of inferential statistics to analyze the MAKSS and CAAT scores using a statistical significance level of 0.05. Data were analyzed using SPSS v25 using paired t tests to compare pretest-posttest results.

RESULTS

Results showed that there was a statistically significant increase in MAKSS and CAAT scores from presimulation to postsimulation. The findings also suggest that participation in this type of exercise may have increased self-assessment of cultural awareness and multicultural awareness, knowledge, and skills among health professions students.

CONCLUSIONS

This study described the planning and execution of a large multiple scenario simulation event that involved 180 students spanning 5 healthcare disciplines. Findings demonstrated that the IP simulation event improved the students' self-assessment of multicultural awareness, knowledge, and skills as well as their own cultural awareness. The exploration of cultural competence and humility should be a priority for simulation-based learning.

Exploring equity, diversity, and inclusion in a simulation program using the SIM-EDI tool: the impact of a reflexive tool for simulation educators

BACKGROUND

There have been increasing calls for awareness and action related to equity, diversity, and inclusion (EDI) in simulation but a lack of practical guidance for how simulation delivery teams (SDTs) might move towards meaningful transformation. The gap between academic conversations about EDI and how to practically impact SDT attitudes, behaviors, and performance remains considerable. We designed a conversational tool, the SIM-EDI, to bridge the gap between theory and practice for SDTs by enhancing reflexivity and studied its impact locally.

METHODS

We engaged in a collaborative autoethnography to explore EDI within our emergency department SDT shortly after implementing the SIM-EDI. The 12-month ethnography is informed by our team's collection and analysis of data about ourselves and our own experiences using the tool. Data included serial interviews, field notes from simulations and SDT meetings, SDT documents, and self-reflections.

RESULTS

We found the SIM-EDI tool could be implemented with a team with a high level of readiness. Use of the tool had several meaningful impacts including enhanced team reflexivity, normalization of conversations related to EDI and increased confidence to engage in EDI conversations with participants. Key themes throughout the process included (1) individual and team growth, (2) fear of "getting it wrong", and (3) tension between bias towards action and need for slow reflection.

CONCLUSION

The SIM-EDI tool can effectively promote reflexivity among faculty in an emergency department simulation program. The tool is easy to use and implement, impacts attitudes and behaviors, and facilitates individual and team growth.

Transforming nursing education in response to the Future of Nursing 2020-2030 report

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report (NASEM, 2021) provides a comprehensive plan to improve the quality of health care and candidly acknowledges historical and contemporary issues that have stalled previous efforts to dismantle health care disparities. This article spotlights the role that nursing education, nurse leaders, and faculty play in enabling all people to achieve their highest level of health. Through the framework of the four pillars of (1) reconciling the shortage of nurses with expertise in public health and health equity, (2) creating policies that include and promote the tenets of diversity, antiracism, and well-being, (3) designing curricular resources and activities that address contemporary issues, and (4) creating and supporting an ethos that invites, retains, and graduates diverse students and facilitates a sense of belonging, our future nursing graduates will be prepared to advance health equity for all.

Attitudes and Actions Related to Racism: the Anti-RaCism (ARC) Survey Study

BACKGROUND

Racism negatively impacts health and well-being. Members of the medical community must intervene to address racism.

OBJECTIVE

To assess whether attitudes about the impact of racism on health or society are associated with intervening around racism.

DESIGN

Cross-sectional survey of a large department of medicine in an urban academic setting.

PARTICIPANTS

Interns, residents, fellows, and faculty.

MAIN MEASURES

The primary outcome was the likelihood of intervening around an observed racist encounter or a racist policy. Predictor variables included age, gender identity, race/ethnicity, and attitudes about racism.

KEY RESULTS

Although the majority of the 948 respondents endorsed the impact of racism on health and other societal effects, levels of endorsement were lower among older individuals, or those reporting male gender identity or selecting other race. Higher endorsement of the impact of racism on health was associated with increased odds of speaking up about a racist encounter or racist policy, with odds ratios from 1.18 to 1.30 across scenarios. Likelihood of speaking up about racism did not differ by racial or ethnic group, but older individuals were generally more likely to speak up and individuals between 20 and 29 years of age were more likely to speak with someone other than leadership or the source of a racist encounter.

CONCLUSIONS

Awareness of the effects of racism on health is associated with increased likelihood of intervening when a racist encounter is observed or a racist policy is noted. Including information on the impact of racism on health and creating safe spaces to discuss racism may increase the likelihood of bystander intervention in anti-racism strategies.

Medical student confidence when training for a female genitourinary exam using models and standardized patients

AIM

The purpose of this study is to investigate what factors make students feel confident and competent when performing a female genitourinary exam (FGUE) with normal, nonpathologic findings. We anticipated that students would increase their confidence and perceived competence from the first year to the second year of medical school, would prefer the use of specialized standardized patients (SSPs) over models, and that the results would vary by student demographics.

METHODS

Student confidence and perceived competence were measured using voluntary survey methods pre- and postinterventions. Interventions were defined as learning the FGUE on models alone for first-year medical students and learning the FGUE on SSPs with prior experience using models for second-year students. Survey responses were evaluated via generalized linear mixed models for numeric responses.

RESULTS

The results demonstrated that first- and second-year medical students of racial and ethnic minorities rated themselves as more confident and competent than Caucasian counterparts, which was in many cases more extensive than the effect of an additional year of medical education. Students felt that using SSPs alone was the best mode of learning the exam than either models alone or the combination of models and SSPs. Students' current specialty of choice did not correlate with increased confidence or perceived competence.

CONCLUSION

This study highlights how cultural differences have an impact on confidence and perceived competence in medical students as they prepare for performing a procedure as intimate to the patient as the FGUE.

The Art of Sim-Making: What to Learn from Film-Making

The components of each stage have similarities as well as differences, which make each unique in its own right. As the film-making and the movie industry may have much we can learn from, some of these will be covered under the different sections of the paper, for example, "Writing Powerful Narratives," depiction of emotional elements, specific industry-driven developments as well as the "cultural considerations" in both. For medical simulation and simulation-based education, the corresponding stages are as follows: DevelopmentPreproductionProductionPostproduction andDistribution. The art of sim-making has many similarities to that of film-making. In fact, there is potentially much to be learnt from the film-making process in cinematography and storytelling. Both film-making and sim-making can be seen from the artistic perspective as starting with a large piece of blank, white sheet of paper, which will need to be colored by the "artists" and personnel involved; in the former, to come up with the film and for the latter, to engage learners and ensure learning takes place, which is then translated into action for patients in the actual clinical care areas. Both entities have to go through a series of systematic stages. For film-making, the stages are as follows: Identification of problems and needs analysisSetting objectives, based on educational strategiesImplementation of the simulation activityDebriefing and evaluation, as well asFine-tuning for future use and archiving of scenarios/cases.