Using simulation and standardized patients to teach vital skills to pain medicine fellows

Simulation-Based Education in Acute and Chronic Pain Training

PURPOSE OF REVIEW

The use of simulation-based education (SBE) in medical training has expanded greatly and has grown to include high fidelity and task simulation along with hybrid models using patient actors to enhance education and training of critical events as well as technical skills.

RECENT FINDINGS

In the field of anesthesiology, SBE has been particularly useful for crisis resource management and rare critical scenarios and new research into the use of SBE using task simulation for procedural skill development has been done highlighting the benefits to subspecialty procedural training. Medical simulation has become a common practice in medical training and research. SBE has demonstrated positive outcomes in improving technical skills, knowledge, comfort, and clinical performance. The widespread implementation of SBE in regional anesthesia and chronic pain training varies, with cost and availability being factors. Nonetheless, SBE has shown great potential in enhancing education and preparing physicians in subspecialties of anesthesia.

The Pain Medicine Curriculum Framework-structured integration of pain medicine education into the medical curriculum

Medical practitioners play an essential role in preventing pain, conducting comprehensive pain assessments, as well as promoting evidence-based practices. There is a need for the development of innovative, interprofessional and integrated pain medicine curricula for medical students. The Pain Medicine Curriculum Framework (PMCF) was developed to conceptualise a purposeful approach to the complex process of curriculum change and to prioritise the actions needed to address the gaps in pain medicine education. The PMCF comprises four dimensions: (1) future healthcare practice needs; (2) competencies and capabilities required of graduates; (3) teaching, learning and assessment methods; and (4) institutional parameters. Curricula need to meet the requirements of registration and accreditation bodies, but also equip graduates to serve in their particular local health system while maintaining the fundamental standards and values of these institutions. The curriculum needs to connect knowledge with experience and practice to be responsive to the changing needs of the increasingly complex health system yet adaptable to patients with pain in the local context. Appropriate learning, teaching and assessment strategies are necessary to ensure that medical practitioners of the future develop the required knowledge, skills and attitudes to treat the diverse needs of patients' experiencing pain. The historical, political, social and organisational values of the educational institution will have a significant impact on curriculum design. A more formalised approach to the development and delivery of a comprehensive pain medicine curriculum is necessary to ensure that medical students are adequately prepared for their future workplace responsibilities.

A novel interventional pain simulation-based education curriculum: Implementation to enhance procedural training

Several studies have demonstrated the benefits of simulation-based education (SBE) across all trainee levels in various medical fields. These benefits include allowing trainees greater autonomy and the opportunity to learn from mistakes in bioethical and procedural scenarios without compromising patient safety. While much progress has been made, there is little research on the implementation of SBE in pain medicine. This study investigated the effects of interventional pain SBE on 37 pain medicine fellows at the Brigham and Women's Hospital Pain Medicine Fellowship. The study found that fellows' performance, knowledge, and comfort were enhanced by the implementation of this curriculum.

The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations for Surgical Technique for Spinal Cord Stimulation

INTRODUCTION

The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice.

MATERIALS AND METHODS

Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant.

RESULTS

This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion.

CONCLUSIONS

The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community.

Interventional Spine and Pain Procedure Credentialing: Guidelines from the American Society of Pain & Neuroscience

Background

The discipline of interventional pain management has changed significantly over the past decade with an expected greater evolution in the next decade. Not only have the number of procedures increased, some of the procedures that were created for spine surgeons are becoming more facile in the hands of the interventional pain physician. Such change has outpaced academic institutions, societies, and boards. When a pain physician is in the credentialing process for novel procedure privileges, it can leave the healthcare system in a challenging situation with little to base their decision upon.

Methods

This paper was developed by a consensus working group from the American Society of Pain and Neuroscience from various disciplines. The goal was to develop processes and resources to aid in the credentialing process.

Results

These guidelines from the American Society of Pain and Neuroscience provide background information to help facilities create a process to appropriately credential physicians on novel procedures. They are not intended to serve as a standard or legal precedent.

Conclusion

This paper serves as a guide for facilities to credential physicians on novel procedures.

Introducing Simulation-Based Learning for Trainees in Chronic Pain Medicine: Needs Assessment and Suggestions for Training Scenarios

INTRODUCTION

Managing patients with chronic pain can be complex and requires specialized clinical knowledge and advanced communication skills. Simulation-based learning has been shown to improve learning outcomes for complex competencies and could be a valuable resource for trainees in chronic pain medicine.

METHODS

We assessed the need for a simulation-based course for trainees in chronic pain medicine at McMaster University in Canada. The needs assessment consisted of three steps: (1) literature review to identify preexisting needs assessments, (2) targeted interviews with six healthcare professionals in chronic pain management, and (3) an analysis of 366 routinely collected patient experience surveys.

RESULTS

The systematic review identified a small body of related literature and no previous needs assessment. We identified the following key competencies and skills that trainees in pain medicine need to develop: (1) communicating with distressed patients using skills such as de-escalation, active listening, and motivational interviewing, (2) managing patients in difficult emotional situations such as poorly controlled pain or showing signs of opioid misuse, and (3) recognizing and managing mental health issues related to chronic pain using appropriate instruments.

DISCUSSION

Suggestions for scenarios included the following: (1) consulting a patient with poor pain control and running out of treatment options, (2) managing a patient with suspected inappropriate opioid use, and (3) diagnosing depression in a patient suffering from chronic pain and developing an appropriate treatment plan.

CONCLUSION

We propose the development of suggested scenarios into simulation-based courses, and test and refine them together with trainees and experts in pain medicine.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01335-6.

An Objective Structured Clinical Examination Case for Opioid Management: Standardized Patient Ratings of Communication Skills as a Predictor of Systems-Based Practice Scores

The Wayne State University Office of Graduate Medical Education (WSUGME) uses an objective structured clinical examination (OSCE) to assess its programs' contribution to enhancing residents' communication skills. In response to revisions in Michigan's opioid-prescribing mandates in 2017, WSUGME developed a pain management case in collaboration with faculty and the Wayne State University School of Medicine to educate residents about these mandates while gauging their skills in Systems-Based Practice (SBP), an Accreditation Council for Graduate Medical Education Core Competency. This study examined whether resident OSCE performance predicted year-end milestones scores in SBP1 (coordinates patient care within various health care delivery settings), SBP2 (works in interdisciplinary teams to enhance patient safety and improve patient care quality), and SBP3 (practices and advocates for cost-effective, responsible care). Participants included two cohorts of first- (PRG-1) and second-year (PRG-2) residents in 6 programs: one cohort from academic year 2018-2019 (n=33), the other from 2019-2020 (n=37). Before the OSCE, WSUGME emailed residents the new state prescription requirements. During the simulated encounter, standardized patients rated residents on a validated communication instrument, and WSUGME conducted a linear regression of patient ratings on resident SBP milestone scores. The ratings of communication skills of PRG-1 residents did not predict any of the year-end SBP milestones. However, ratings of communication skills of PRG-2 residents predicted SBP1 and SBP2, though not SBP3, milestones. The OSCE opioid case proved to be a valid measure of PRG-2 residents' competence gained across the first year but was less meaningful when applied to PRG-1 residents.

Pain medicine fellow neuromodulation surgical skill assessment tool: a pilot

OBJECTIVE

Spinal cord stimulation (SCS) is an evidence-based therapy for the treatment of refractory pain. Current American College of Graduate Medical Education requirements for pain medicine fellowship graduation include observation of five neuromodulation cases. Matriculating fellows have varying degrees of technical skill, training, and experience. The purpose of this study was to use an innovative skill-based assessment tool using the validated Zwisch scale to evaluate fellow surgical performance during SCS cases.

DESIGN

Cross-sectional survey SETTING: Mayo Clinic, Rochester, Minnesota.

SUBJECTS

Consultant faculty (10) in the Division of Pain Medicine and pain medicine fellows (5).

METHODS

A list of faculty-driven neuromodulation surgical objectives was formed and a rubric was created that focused on technical approach, imaging, epidural access and wound closure. Consultants who perform surgical cases were instructed to use the Zwisch scale as a guide to evaluate fellow surgical performance during a neuromodulation case. Faculty and fellows were surveyed before and after implementation of the tool to determine their satisfaction with use of the skill assessment tool.

RESULTS

The consultants reported they were more satisfied, consistent, and efficient with feedback provided to the trainee on every aspect of neuromodulation surgical cases. The improvement was most significant during the fellows' intraoperative skill assessment. The fellows indicated increased satisfaction, improved communication, and increased efficiency of feedback when the tool was utilized. The fellows reported greater intraoperative skill assessment and consistency of feedback provided.

CONCLUSIONS

The diverse nature of primary specialty backgrounds observed in pain medicine fellowship training offers a unique opportunity to assess and improve fellow skill and surgical competence in the field of neuromodulation. Both faculty and fellows reported improved satisfaction, consistency and efficiency with feedback provided. Importantly, this pilot project observed that implementation of a skill assessment tool was beneficial for both the faculty and fellow as the feedback received was viewed as strongly beneficial to the educational experience.

Advancing Simulation-Based Education in Pain Medicine

Background

The Accreditation Council for Graduate Medical Education (ACGME) has recently implemented milestones and competencies as a framework for training fellows in Pain Medicine, but individual programs are left to create educational platforms and assessment tools that meet ACGME standards.

Objectives

In this article, we discuss the concept of milestone-based competencies and the inherent challenges for implementation in pain medicine. We consider simulation-based education (SBE) as a potential tool for the field to meet ACGME goals through advancing novel learning opportunities, engaging in clinically relevant scenarios, and mastering technical and nontechnical skills.

Results

The sparse literature on SBE in pain medicine is highlighted, and we describe our pilot experience, which exemplifies a nascent effort that encountered early difficulties in implementing and refining an SBE program.

Conclusions

The many complexities in offering a sophisticated simulated pain curriculum that is valid, reliable, feasible, and acceptable to learners and teachers may only be overcome with coordinated and collaborative efforts among pain medicine training programs and governing institutions.

Use of Immersive Learning and Simulation Techniques to Teach and Research Opioid Prescribing Practices

INTRODUCTION

Unsafe opioid prescribing practices to treat acute and chronic pain continue to contribute to the opioid overdose crisis in the United States, a growing public health emergency that harms patients and their communities. Poor opioid prescribing practices stem in part from a lack of education and skills training surrounding pain and opioid management.

METHODS

As part of the Clinical Pain Medicine Fellowship at Stanford University, physicians were given the opportunity to participate in a pilot program to practice opioid management in a live, simulated interaction. Twenty-seven physician trainees participated in the simulation with a live, standardized patient actor. Before beginning the simulation, participants were given a detailed patient history that included the patient's risk for opioid abuse. They were also provided with relevant risk evaluation and mitigation (REM) tools. All simulation interactions were video-recorded and coded by two independent reviewers. A detailed coding scheme was developed before video analysis, and an inter-rater reliability score showed substantial agreement between reviewers.

RESULTS

Contrary to expectations, many of the observed performances by trainees contained aspects of unsafe opioid prescribing, given the patient history. Many trainees did not discuss their patient's aberrant behaviors related to opioids or the patient's risk for opioid abuse. Marked disparities were also observed between the trainees' active patient interactions and their written progress notes.

DISCUSSION

This simulation addresses a pressing need to further educate, train, and provide point-of-care tools for providers prescribing opioids. We present our experience and preliminary findings.

The use of theatre in medical education in the emergency cases school: an appealing and widely accessible way of learning

INTRODUCTION

Theatre models in medical education have been used worldwide in order to train medical students and graduates in managing various situations. However, the literature reports little regarding its appeal to trainees. We conducted a medical seminar, entitled Emergency Cases School, which employed such techniques. Actors simulated the actions of doctors and patients involved in various emergency cases, in front of a large audience, in a specially modified theatre hall which resembled the emergency room environment.

METHODS

A total of 303 undergraduate medical students participated in the seminar. The audience evaluated the course with the DREEM questionnaire, along with two extra questions: Q1. 'Do you think that the course will prove itself beneficial to your clinical skills?' and Q2. 'Would you suggest the course to another student?', in a 0-4 scoring scale. Of the attendees, 281 (92.7%) answered the questionnaire.

RESULTS

The overall DREEM score was 140.32 (±23.39) out of 150, which is interpreted as 'More positive than negative'. The results of Q1 and Q2 were 3.07 (±0.78) and 3.65 (±0.61), respectively.

DISCUSSION

The Emergency Cases School received positive feedback as a theatre educational tool, targeted to a large audience. With the advantage of the realistic setting of an emergency room, along with its low-budget needs, this course model could function as a creative alternative of the more traditional lecturing teaching techniques.