Simulation-based learning Translates to Clinical Outcomes
by Sarah Plumridge
In the lower level of McGaw Pavilion, a set of glass doors opens to Northwestern Simulation, a space where countless students, trainees and medical professionals have strived to perfect their clinical skills by participating in simulation-based learning.
Here in the simulation center, Feinberg instructors facilitate a type of competency-based education called mastery learning, which requires students to demonstrate they can perform a skill or task in a simulated environment before working with actual patients.
Studies show that implementing this strategy across undergraduate, graduate and continuing medical education not only improves procedural and communication skills at the bedside, it also leads to better patient outcomes, retained skills and reduced healthcare costs.
According to William McGaghie, PhD, a professor of Medical Education and Preventive Medicine who pioneered mastery learning at Northwestern, it also leads to “excellence for all,” with all learners accomplishing all educational objectives with little or no variation in performance.
“Traditional clinical education is often taught using old-fashioned methods that don’t always work very well,” McGaghie says. “At Northwestern, we set up conditions that allow our bright, hardworking students and trainees to succeed.”
During mastery learning, students have a predetermined mastery standard they must achieve to pass a curriculum. After taking a pretest, they perform deliberate practice where they complete multiple focused task repetitions while instructors provide immediate feedback and correct errors. Once learners feel they are performing at a high level of competency, they take a graded assessment. If they don’t meet the benchmark, they continue training and retesting until they’ve acquired the skill. While practice time varies between individuals, the results are uniform — eliminating performance variability.
McGaghie experienced mastery learning techniques as an undergraduate student in a statistics course. His continued interest led him to write a book on mastery learning in competency-based education for the World Health Organization in the late 1970s. And now, nearly 40 years later, the concept is flourishing at Northwestern.
Mechanisms of Education and Healthcare Delivery
Over the years, McGaghie has mentored a number of academic physicians in mastery learning, beginning with Diane B. Wayne, ’91 MD, the Dr. John Sherman Appleman Professor and Feinberg’s vice dean for Education.
A decade ago, Wayne compared how second-year internal medicine residents applied advanced cardiac life support protocols after receiving simulation-based education versus clinical experience alone. She found that residents who underwent the simulation training performed 38 percent better than the group who had not received additional training. They could also recall and use what they learned up to 14 months later. These results were published in journals including Academic Medicine.
“How can we use medical education to address clinical care quality issues at the bedside? To be a world-class education program you have to think carefully about this and then study it,” says Wayne, who in 2007 received the National Award for Medical Education Scholarship from the Society of General Internal Medicine and the Thomas Hale Ham Award for New Investigators from the Association of American Medical Colleges (AAMC) for her groundbreaking work.
“I think education is underappreciated for the ability to translate into clinical outcomes,” she adds. “Our research impacts the field of medical education on a fundamental level, is applicable at all medical schools in the country and has the ability to be implemented and reproduced in many different settings.”
Wayne and McGaghie have gone on to mentor other investigators interested in mastery learning, leading to research projects exploring central venous catheter insertion, common bile duct surgical procedures, intensive care unit ventilator management, healthcare communication and more.
Since 2006, Jeffrey Barsuk, ’99 MD, ’02 GME, professor of Medicine in the Division of Hospital Medicine and of Medical Education, has used simulation-based mastery learning to train second- and third-year internal medicine residents on central line insertion a month before their rotation in the intensive care unit.
Central lines are typically inserted into the jugular vein to give medications or fluids, take blood for testing and measure blood pressure near the heart. Thanks to Barsuk’s training, the rate of central line-associated bloodstream infections from central lines inserted by Northwestern internal medicine residents has fallen dramatically. Complications such as arterial puncture and the number of times the skin was punctured have also been reduced. When annual savings from reduced infections were compared with the annual cost of simulation training, the investigators found a seven-to-one return on investment in one year.
“Using traditional methods, mastery often can’t be accomplished because residents cannot focus on pure learning, and they don’t have enough opportunities to practice,” says Barsuk, who also received a Thomas Hale Ham Award for New Investigators from the AAMC in 2010 for his work.
In 2012, Barsuk and his team rolled out another training on lumbar puncture skills and published the results in the journal Neurology. In this study, first-year internal medicine residents at Northwestern who went through simulation-based mastery learning were compared to neurology residents in their second, third and fourth years from three other Chicago academic institutions that received standard residency training. Northwestern’s first-year residents scored 46 percent higher than the residents with more extensive training and clinical experience.
“Mastery learning requires a high performance standard and allows us to eliminate much of the variability in healthcare provider skills,” Barsuk says. “Using this model has the ability to improve patient safety and reduce healthcare costs in an innovative and novel way.”
Eric Hungness, MD, ’05 GME, associate professor of Surgery in the Division of Gastrointestinal and Oncologic Surgery and of Medical Education, saw similar results after delivering a new training course on a common bile duct procedure used to remove gallstones.
In previous studies, Hungness found that laparoscopic common bile duct exploration (LCBDE) treatment for removing gallstones and the gallbladder was underused, despite its clinical advantages. He believed it was due, in part, to a lack of exposure to LCBDE during residency training.
“We are continually trying to innovate in surgical education,” says Hungness, who is also the S. David Stulberg, MD, Research Professor. “We didn’t feel like we had quality teaching tools, so we had to develop them ourselves.”
Hungness implemented a mastery learning curriculum for senior general surgery residents and showed that it improved confidence and performance to mastery level. He published the results in the journal Surgery in 2014. Now he’s evaluating the effect of the curriculum on clinical utilization, safety and efficacy of the procedure at Northwestern Memorial Hospital. Preliminary data shows an increase in the number of LCBDE procedures from less than 10 percent to 20 percent. It’s saved the hospital nearly $40,000 over three years and has a potential return on investment of nearly 15-to-one.
Another important benefit: “It’s rewarding to see the residents developing their skills and hear some of the stories about patients being directly impacted,” Hungness says.
Mastery Learning in Undergraduate Medical Education
Since then, medical students have mastered everything from technical procedural skills to communication and interpersonal skills in the rooms of Northwestern Simulation. David Salzman, ’05 MD, ’09 GME, MEd, director of Simulation for Undergraduate Medical Education and assistant professor of Emergency Medicine and Medical Education, has developed courses to closely align classroom instruction with relevant, hands-on clinical experiences.
At other times, the simulation center hosts courses such as “Breaking Bad News” and “Difficult Conversations,” led by Julia Vermylen, ’11 MD, ’11 MPH, ’14 GME, instructor of Medicine, and Gordon Wood, MD, ’07 GME, assistant professor of Medicine, where students apply mastery learning techniques to simulations with standardized patients.
“A conversation is a procedure, and like any procedure, it can have lasting complications,” Wayne says. “A focus on communication skills ensures that our graduates possess all of the clinical skills they need to competently care for patients starting on day one of their residency training.”
This innovative curriculum also includes early patient experiences, such as the Education-Centered Medical Home (ECMH), a longitudinal clerkship. During the ECMH experience, teams of medical students are embedded into primary care clinics throughout their four years to practice clinical skills and to provide continuity of care to patients. The model differentiates itself from traditional education by allowing students to serve as patient advocates and act as educators.
One of the students who participated in the pilot ECMH in 2011, Bruce Henschen, ’12 MD, ’12 MPH, ’15 GME, now assistant professor of Medicine in the Division of General Internal Medicine and Geriatrics, has continued to be involved in the program. In a 2015 paper in Academic Medicine, he assessed the outcomes of ECMH on both student education and patient care. He discovered that students who spent time in the ECMH curriculum were more satisfied with their primary care education overall, and they recommended the ECMH to incoming medical students. In addition to educational outcomes, the study found that patients enrolled in the ECMH clinic benefited as well through higher rates of preventive care including influenza vaccination and cancer screenings.
“Students also reported more encouragement from their preceptors to make meaningful connections with patients — a critical skill for all future practicing physicians,” Henschen says. In recognition of this innovative education model, Henschen received the 2016 Thomas Hale Ham Award for New Investigators from the AAMC — representing the third time a Northwestern faculty member won this award for medical education research over the past decade.
Improving Health for Individuals and Populations
Going forward, Northwestern faculty are expanding the scope of these models and beginning to apply mastery learning to other departments at Northwestern, as well as across the country and world.
“We are creating the next generation of investigators in medical education research,” Wayne says. “By working with the health system on identifying quality targets, we can translate our classroom results to achieve better health outcomes for patients.”
With support from an NIH grant, Barsuk is even expanding simulation-based mastery learning to train heart failure patients and their caregivers on how to use ventricular assist devices, which are implanted into the heart to help pump blood flow.
“We knew one of the next steps for our work was patient self-management skills,” Barsuk says. “There is very little published research using simulation training with patients and nothing on mastery learning with patients, so we thought this was a natural fit.”
Patients and their caregivers are responsible for changing the device’s batteries, working its controller and changing the dressings over the entry into the skin. Currently, Barsuk and his team are creating the curriculum and simulator, and training will begin soon.
“When we think about quality issues, a lot of providers don’t think about education as a solution,” Barsuk says. “The more studies and evidence we provide, the more we will show that rigorous training such as mastery learning has a large role in improving healthcare outcomes.”