Education/original researchImproved Medical Student Satisfaction and Test Performance With a Simulation-Based Emergency Medicine Curriculum: A Randomized Controlled Trial
Introduction
In a 2005 systematic review of high-fidelity medical simulations, Issenberg et al1 identified the need for additional research to demonstrate the effectiveness of simulation in education and assessment. Their review found that only 20% of high-fidelity simulation studies addressed the effectiveness of learning or reported findings “that are clear and probably true.” The remaining 80% were judged to be “equivocal at best.” They concluded that although the quality of studies conducted to address learning with high-fidelity simulation is a limitation, “it works under the right conditions.” Several subsequent studies that demonstrated simulation to be an effective training tool for clinical and teamwork skills were not designed to rigorously compare simulation with other method of instruction.2, 3, 4, 5, 6, 7, 8, 9, 10 Ali et al11 evaluated the effect of simulation on written test results and demonstrated a statistically significant improvement in medical student performance on a multiple choice posttest after the addition of 2 hands-on trauma resuscitation stations to a trauma evaluation and management program. However, their intervention was an addition to the standard curriculum and not a comparison of simulation to the standard curriculum. Studies evaluating the effect of simulation on test performance compared to didactic formats have not been conclusive. Wong et al12 conducted a randomized controlled study to compare the effectiveness of instruction with a human patient simulator with that of a standard lecture for second-year medical students learning about the pathophysiology of shock. The simulator group performed slightly better on the posttest compared with the lecture group, but the sample size was small and the results did not achieve statistical significance.12 Gordon et al13 compared a single intervention of simulator-based teaching with traditional lecture-based instruction for third-year Harvard medical students. They found a significant difference between preintervention and postintervention performance on a short answer test in both groups, but the difference between the simulation and the lecture groups was not significant. Studies evaluating student satisfaction with human patient simulator sessions have demonstrated high satisfaction levels.14, 15, 16, 17 However, conclusive quantitative assessment of the degree of learning and student satisfaction achieved with simulation compared with didactic forms of teaching is lacking in the literature. To more comprehensively evaluate the effect of simulation on student test performance and satisfaction, we compared a simulation-based format for a medical student curriculum in emergency medicine with an established case-based group discussion format.
Section snippets
Goals of This Investigation
Our primary goal was to compare the effectiveness of a simulation-based format for a fourth-year medical student emergency medicine clerkship curriculum with a case-based group discussion format using the scores on a standardized multiple choice final examination. The independent variable was teaching format and the dependent variable was the number of incorrect answers on the final examination. Our secondary goal was to evaluate student satisfaction with simulation compared with the case-based
Results
During the study period, 91 of 91 eligible subjects were enrolled and completed the informed consent. Ninety (99%) students successfully completed the clerkship, providing 90 sets of scores on the multiple choice questions. Two students completing the clerkship did not complete the satisfaction survey, and thus there were 88 responses (97%) constituting the students' satisfaction with simulation compared with the case-based group discussion format.
The total number of questions answered
Limitations
This study had several important limitations. First, although the number of students enrolled in the study was adequate to demonstrate a statistically significant difference in performance on a multiple choice test, the results are representative of students from a single medical school. There were a few visiting fourth-year students from other institutions, but the number was too small to assess external validity. Second, the mean examination score for the class was 88%, which was higher than
Discussion
Both group discussion and the simulation laboratory offer settings that are controlled, recordable, and safe.21 In addition to providing an interactive method of knowledge transfer, both formats allow students to gather information, develop a differential diagnosis, and solve problems. However, the simulation laboratory offers students the opportunity to practice additional clinical, technical, and teamwork skills compared with group discussion while still providing a safe environment in which
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Supervising editor: Peter C. Wyer, MD
Author contributions: RPTE conceived the study, designed the trial, and obtained institutional review board approval. RPTE, MT, and JMB designed the curriculum, determined the learning objectives, and created the individual session debriefing slides. RPTE wrote the simulation programs and MT conducted a pilot session. RPTE and JMB conducted subject recruitment, simulations, and some of the group discussion sessions. RPTE managed the data, including quality control, and worked with the university's statistical consulting center for analysis of the data. RPTE drafted the article, and all authors contributed significantly to revisions. RPTE takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. No external funding was involved in completion of this study, and none of the authors have any financial interest in the product studied or the company that produced it.
Publication date: Available online April 25, 2009.