SImulations Can Work Well in Medical Education.

There are lots of ways to teach things, but we know that to develop real expertise in a skill, they need the chance to practice and to get feedback.  One way that people can get that practice and feedback, is by simulating the work environment.  Simulations are being used more often in medical education, and they've proven to be effective, if done correctly. 

A recent review of simulations in medical education looks at some of the aspects that make learning from simulations effective.  They include:

• Feedback
• Deliberate practice
• Curriculum integration
• Outcome measurement
• Fidelity to the work environment
• A mastery learning environment
• Transfer to practice

These are the usual suspects in effective learning environments - especially practice and feedback.  We should try to incorporate these elements as often as we can when we're designing learning environments for skill learning. 

A Critical Review of Simulation-Based Medical Education Research: 2003 - 2009, Medical Education, 2010, 44:50-63. 

Teaching and Learning in the Year 1011

Learning 1011 AD and 2011 AD, courtesy of Nathan Wallen

Let's go 1000 years back in time to set up a learning event. How would you do it? You would probably bring the expert, and the students into the same room, have the students sit on hard wooden benches, and arrange to have the expert stand in front and transfer his knowledge to the students. This kind of direct teaching was was one of the few options available, and it was reasonably efficient, which is why it was used for thousands of years.

Now, of course, we don't need to be in the same room with an expert to learn. We can interact with many different experts, with other learners, and with many different representations of the content. We can design learning environments and online spaces that help people practice, work through problems, and get feedback. If there's a need to listen to an expert lecture, we can record the lecture and let people view it whenever they want. And the good new is, we have a lot of data that shows that of these kinds of activities will result in better learning, and will be more likely to actually improve professional practice.

So, other than the hard wooden chairs, why does so much professional continuing education in 2011 look exactly the same as it would have in 1011?  It doesn't have to be that way, we can help professionals continue to learn and improve.  

Pseudoteaching

The Action-Reaction blog has an interesting post on "pseudoteaching" at MIT. They have defined pseudoteaching as teaching that looks like good teaching, but pseudoteaching doesn't help students learn. Pseudoteaching that's entertaining may look like good teaching to everyone involved - the teacher, to the students, and to observers, even though it's not very effective.

The post highlights John Lewin, a highly regarded physics professor who "clearly loves physics, and he loves sharing it with his students." His lectures were carefully rehearsed, practiced, and extremely entertaining.

The problem? The failure rate in his classes were too high, and by the end of the term, only 40% of students were attending his classes.

"...Lewin was pseudoteaching. It looks like good teaching, but he was the one doing all the talking. It looks like the students are learning, but they were just sitting there watching. It’s like trying to learn to play piano or play a sport by watching your teacher or coach. It doesn’t work well."

MIT is now using a hands-on approach, called TEAL (Technology Enhanced Active Learning), which has students and teachers doing experiments together, and working through problems.

Unfortunately, much of the teaching that happens in CME is pseudoteaching: Lectures that talk at people, rather than helping them work their way through problems and cases. The real value that experts can bring to a classroom is not the facts they know, but the ways that they think through problems. We know that lectures don't work in CME, It's been shown time and again that lecturing to professional does not change practice behavior. It's time to use more effective methods.



Lewin's lectures look very entertaining, but entertaining students, and actually helping them learn are not always the same thing. This is what MIT has moved away from:

More Positive Results for Spaced Education

In my last entry, I talked about the learning benefits of spaced education for 3rd year medical students doing a urology rotation. Spaced education means simply extended the learning and practice over time. The study I referenced looked at learning after giving students a series of questions using email and found better learning results for the students who had received this kind of education.

The authors of that study did a follow-up study (Journal of Urology, 2009, 181:2671-2673) and found that the benefits of that treatment could still be found, more than 2 years later. This is an amazing result for an educational study. It will certainly need to be replicated but it is very encouraging and speaks to the strength of spacing education out over time.

The authors found that students who had received the spaced education did significantly better on a test of the material than students who had not received the spaced education intervention. The test questions they were given were different from the questions they had answered in the original study (but were from the same batch so they were somewhat similar).

Spaced education and practice can be used fairly easily by using email or even mobile devices, a matter of spreading the practice over time. It should be used more often in CME applications.

Learning from email

One of the things that I want to explore on this blog are the techniques that have been particularly successful in medical education and CME. In 2007, a study was published in Medical Education, that I find particularly interesting (Medical Education, 2007, 41(1):23-31.)

The paper looked at the effect of "spaced education" which has been a consistently strong way to deliver education and training. Spaced education is simply education that's delivered over time. Instead of an hour of straight learning, you might have 10 minutes of learning once a day for six days. Spaced education is powerful, results of studies over may decades have shown that spaced education is more efficient, and it's more effective than "massed" learning. It's perfect for the tools we have available today, such as email and mobile technology.

The authors of the study used a pretty simple intervention. Third year medical students, in a one week urology rotation, were sent 10 - 13 emails with multiple choice questions or simple cases related to their urology learning objectives. . They got the emails over a period of up to 11 months. At the end of the academic year, they took a test on the content.

The students who had received the spaced education did significantly better on the test, and the strongest effects were up to 11 months after the intervention.

I like this study and its simple design - it used a powerful, and tested, learning technique and paired it with a ubiquitous tool (email), to get a strong outcome. I think we're likely to see more spaced educational interventions in the future.

Guidelines for CME

In developing CMEs, I've always tried to make sure that the program incorporates, or at least mentions, any relevant clinical practice guidelines. There are, afterall, the best collective wisdom that we've got. That's why I was excited to stumble onto the Evidence-Based Guidelines for CME recently published in a special supplement of Chest (Chest, 2009, 135, Supplement).

There's lots of information for developers of CME programs, and for those researching CME effectiveness. The Guidelines cover the effect of CME on knowledge, practice performance, clinical outcomes, and include a discussion on audience characteristics and external factors in CME, and the use and effectiveness of simulations.

What Works to Change Practice

What can we do to help physicians improve their practice? There is research that can help guide decisions and priorities. In a 1998 “review of reviews,” looks at methods that have improved practice. The educational message is pretty clear – didactic methods will not work, we need to include education that that helps physicians think about, and practice their new knowledge.




Consistently Effective Interventions

Reminders (manual or computerized)

Multifaceted interventions

Interactive educational meetings that include at least include discussion or practice



Interventions of Variable Effectiveness

Audit and feedback

Local opinion leaders

Local consensus processes

Patient mediated interventions



Interventions with little or no effect

Educational materials, including clinical practice guidelines, recommendations for clinical care, audiovisual materials, and electronic publications

Didactic educational meetings





Bero, L.A., Grilli,R., Grimshaw,J.R., Harvey, E., Oxman, A.D., and M Thomson (1998) Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ; 317 : 465.