Development of an intensive simulating training program in emergency medicine for medical students in China

Xin Lu, Shi Feng, Shi-gong Guo, Mu-bing Qin, Xiang-ning Liu, Shi-yuan Yu, Li-na Zhao, Zeng-zheng Ge,Jing-jing Chai, Sheng-yong Xu, Di Shi, Ji-hai Liu, Hua-dong Zhu, Yi Li

1 Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China

2 Department of Rehabilitation Medicine, Southmead Hospital, Bristol BS105NB, United Kingdom

KEYWORDS: Emergency medicine; Medical education; Simulation; China

To prepare medical students for qualification and postgraduate residency training, it is recommended for medical students to undergo a formal standardized educational rotation in emergency medicine (EM) including specific competencies concerning procedural skills.Currently, the USA and Canada have a consensus in terms of an established EM curriculum.Competencies in 24 procedural skills and their indications, contraindications,and complications are recommended for the USA medical students to pass during their 4-week rotation.However, a national standardized EM curriculum for medical students,including specific competencies in procedural skills, is absent in many other countries. In addition, there is a serious shortage of emergency physicians in many countries.Furthermore, patients can suffer from emergency lifethreatening conditions in any location including the inpatient ward, outpatient clinic, or community setting. Therefore, all future physicians need to be competent in the management of emergency conditions.

Another widely shared problem in EM education is the limited duration of clinical rotations, which in turns impedes the implementation of a well-recognized EM training program. According to our former survey, the average duration of a clinical rotation in EM education of medical students enrolled on the 8-year integrated Doctor of Medicine (MD) programs in China is two weeks, with a minimum of three days on the said program at Peking Union Medical College (PUMC). Therefore, the development of an intensive simulating training program in EM, based on this tight schedule is anticipated to enhance the competency of medical students. This innovative training may equip students with the knowledge and confidence to apply what they have learned into clinical practice post-qualif ication.

A 3-day intensive EM training program was developed by experienced physicians from the EM department in Peking Union Medical College Hospital (PUMCH), each equipped with Basic Life Support (BLS) and Advance Cardiac Life Support (ACLS) certification awarded by American Heart Association (AHA). These experienced physicians are attending EM physicians with a strong background in medical education, including setting up and delivering emergency knowledge and procedural skill courses on at least a yearly basis.

The intensive EM training consists of four procedural skills and 8-hour case-based learning (CBL)concerning six typical diseases or medical conditions that present to the EM department. The word “intensive” is described as massed learning the amount of information taught in a short period. Emergency knowledge and skills are taught in the concentrated 3-day curriculum. There are four procedural skills consisting of 4-hour training sessions in each of the following: BLS and ACLS resuscitation skills,tracheal intubation, venipuncture, and emergency bedside ultrasonography. BLS and ACLS resuscitation skills include cardiopulmonary resuscitation (CPR), tracheal foreign body extraction, and electrical defibrillation. The six diseases or medical conditions are poisoning, shock, chest pain, acute abdomen, electrolyte disturbance, and hemodialysis. For the benefit of the medical students, the skills are trained in a simulated environment. Simulation is known as the artificial representation or mimicking of a real-life situation,environment, or event that provides an experience for learning,evaluation, or research. High-f idelity mannequins and trained standardized patients are involved in the curriculum.

We enrolled medical students who had been in clinical rotations or clerkships for one year and had begun their EM rotation, in effect, 6-year medical students from PUMC and 7-year medical students from Tsinghua University (THU).Students were excluded from the study if they did not complete the 3-day intensive EM training.

Three written tests were cautiously designed to examine the outcomes of the training, covering the vital knowledge of six typical diseases and four procedural skills taught in the training program. The total scores of every test were 25 points. The English versions of the three tests are attached in supplementary file 1. Three tests were adjusted to the same level of difficulty and carried out before the training program, immediately after the training, and 6 months after the training program, evaluating the short-term and long-term efficacy of the training. Different questions were found in the pre- and immediate post-training tests, which examined different aspects of the same topic. This was done to prevent rote memorization of the same questions by students. The questions for the test carried out 6 months later were selected from the previous two tests in order to maintain the same level of difficulty.

After completion of the training program, an online personal appraisal questionnaire was distributed on WeChat(a mobile messaging App commonly used in China). The questionnaire was translated into English and attached in supplementary file 2. Students were asked to anonymously rate their self-perceived skill level and competency in each of the aforementioned EM training domains.

The rating level ranged from 0 to 5 (0 being nothing learnt to 5 being the most fruitful learning experience).The same questionnaire was also dispensed voluntarily to the 7- and 8-year medical students from PUMC(120 students) and the 8-year students from THU (20 students), who spent three days in the EM department of PUMCH without receiving intensive training. Because students in the same year all participated in the 3-day curriculum, senior students in the years above, who had not gone through the new training program, were chosen as the non-concurrent control group.

We reported continuous variables as means with standard deviation (SD) under normal distribution and analyzed by Student’s t-test, and as median with interquartile range under skewed distribution using Wilcoxon signed-rank nonparametric test. Categorical variables were expressed as frequencies with percentage and compared using Chisquare test. A two-tailed alpha ＜0.05 represented statistical signif icance. All analyses were performed using SPSS (SPSS Statistics 25, IBM Inc., USA).

Eighty-one 6-year medical students from PUMC and 20 7-year medical students from THU completed the intensive training and took the tests. Among them, 2 PUMC students and 2 THU students failed to participate in all three written tests and were thus excluded from the study. Two students failed to f inish the f irst test because of illness. Two students had difficulty in arranging the third test because they went abroad for scientif ic research. Finally, 79 (97.5%)students from PUMC and 18 (90.0%) students from THU were included. Scores of the other students were collected and analyzed. There was a significant increase in the average score after the intensive simulating training program(pre-training 13.84 vs. 15.57 post-training,＜0.001).The accuracy of procedural skills increased from 0.55 to 0.74 (Table 1). Compared with the pre-training test, 63(64.9%) students made progress, while 22 (22.7%) students surprisingly scored lower in the test immediately taken after training, and 12 (12.4%) students achieved the same mark. To check for the long-term efficacy of the intensive training program, a third test was scheduled for 6 months after the program. There was no significant difference in scores between the tests taken immediately after the program and 6 months later (15.57±2.22 vs. 15.38±2.37,=0.157).The contents of knowledge and procedural skills assessed between the post-training tests were similar, respectively(Table 1).

There was no signif icant difference in scores of the three tests between medical students from PUMC and THU (pretraining 13.91 vs. 13.55, post-training 15.53 vs. 15.69, 6 months after training 15.32 vs. 15.63), regardless of their year of study.

We received 70 responses from PUMC and 16 from THU, referred to as group A. The response rate of group A was 0.85 (86/101). Among those responses, 83 were considered valid. Forty-five questionnaires were collected from the senior medical students from PUMC and THU,referred to as group B. The response rate of group B was 0.32 (45/140). Self-evaluation and achievements of various aspects based on a 0-to-5 scale were conducted to see whether students felt that their learning was fruitful. Students in group A rated a higher score in all diseases and procedural skills (Table 2). Group A got an average score of 4.18 which was higher than the 2.66 marks in group B, especially when it came to the achievements in procedural skills. Nine students in group A claimed that they developed an interest or preference in becoming an EM physician thanks to the intensive training program. In contrast, only one student from group B intended to work in EM after graduation.

Table 1. Test scores and accuracy of disease knowledge and procedural skills of three tests

Table 2. The disease knowledge and procedural skills learnt in emergency medicine1

Our study demonstrated that an intensive training program focused on procedural skills enhanced both the knowledge of common diseases and procedural skills in medical students. The results of three written tests demonstrated the effectiveness of the training program both in the short term and in the long term. However,over 6 months, there was an overall reduction in the knowledge of the students concerning the six diseases without signif icant difference. This could be attributed to the fact that the tight training program mainly focuses on procedural skills rather than knowledge.

On account of the limited training time, the efficiency was most obvious immediately after the program and gradually faded with time. This suggests that a longer program covering more advanced contents is required to reinforce students’ knowledge and competencies in EM.Our program aroused medical students’ interest in EM, and more students were considering EM as a career choice after undertaking our EM training program. Furthermore, patients can suffer from emergency life-threatening conditions on any ward, clinic or community setting. Therefore, EM training can equip medical students with skills and confidence to manage acutely unwell patients in whatever specialty they enter post-qualif ication.

In recent years, there has been tremendous growth in simulation training in undergraduate EM education.Simulation tends to be especially helpful in establishing a constructive scenario for medical students to practise their skills.Simulation provides a safe learning environment,without fear of causing clinical harm and perceived associated blame, thus producing a relaxed and encouraging environment to learn particularly challenging skills. Our results prove that simulation is a reliable method to increase confidence and performance in the resuscitation of patients in the EM department.

Several limitations should be considered when interpreting our results. Firstly, as it was mandatory for all post-one-year clinical clerkship students to undergo the new training program, with no concurrent control group, this meant that the non-concurrent group of senior students in years above was not directly comparable.Senior students may have acquired more EM knowledge and skills indirectly as general learning skills and maturity through their extra years of education. Thus, this could be a noticeable confounding factor when interpreting the results. In the future, we intend to let same-year students voluntarily choose whether to participate in the new training program or not, in order to have a more directly comparable concurrent control group. Secondly, the intensive simulating training program is feasible for large,relatively well-funded and well-equipped medical schools such as PUMC and THU with small class sizes. However,for schools that are less well-funded or equipped, with large class sizes, this type of small group simulation teaching may not be possible. In addition, future studies with more medical schools and more comparable sample sizes may be needed to comprehensively evaluate the outcomes of this new training program. Thirdly, as we evaluated the efficacy of the training partly through selfreported outcomes/appraisal, this may lead to responder bias. In addition, the response rate of the personal appraisal questionnaire in the control group was very low,which may lead to sampling bias.

Our study shows that the introduction of a standardized intensive training program in EM focusing on key competencies can improve clinical confidence, knowledge,and skills of medical students toward the specialty. For those students who have completed this new training program,their eventual performance when encountering an acutely unwell patient in the clinical setting should be explored in a future follow-up study. In addition, having such a program can also enhance student’s interest in EM as a career choice which may enhance recruitment into the specialty and workplace planning.

This study was supported by grants from Chinese Academy of Medical Science Teaching Reform Research Fund (2018zlgc0101); Chinese Academy of Medical Science Online Open Course Construction Fund (J2009022861); CAMS Innovation Fund for Medical Sciences (CIFMS) (serial number 2021-1-I2M-020); and CAMS Innovation Fund for Medical Sciences (CIFMS) (serial number 2020-I2M-C&T-B-014).

Approval from the hospital’s institutional review board was obtained before starting the study.

There are no f inancial or other conf licts of interest related to the submitted article.

XL and SF contributed equally to this work. All authors contributed to the design and interpretation of the study and to further drafts.

All the supplementary files in this paper are available at http://wjem.com.cn/EN/10.5847/wjem.j.1920-8642.2022.004.