The effect of early clinical simulation exposure on fourth-year medical student academic performance
Tagged: Medicine & Healthcare
CHAPTER II: Literature Review
The purpose of teaching is to assist information acquisition while also instilling an interest in the subject and a desire to learn more. Medical professionals have a lot of information and expertise to learn, not just during their official academic years, but it is a life-long process for them to stay up to date on the latest breakthroughs and changes in patient care. This may be a challenging undertaking that requires a significant amount of effort and time. Add to that the development of technical skill sets essential for clinical medical practice. Technical skills must be learned on the job and with actual patients. Non-technical abilities like attitudes, interpersonal relationships, communication, patient care, and empathy are no longer valued. All of these competence training requirements broaden the scope of primary medical education. Medical school graduation is already one of the longest and most challenging undergraduate courses, and students should not be burdened anymore. What is needed is a more effective technique of instruction, an integrated approach that makes teaching more efficient in terms of time and effort. The necessity for improvements in medical education is widely acknowledged, and most nations have already begun introducing new integrated teaching curriculum in recent decades (Kharb, 2013).
2.1 Traditional medical education
Traditional medical education includes a first year or year and a half of preclinical fundamental sciences such as anatomy, physiology, and biochemistry. This first year of medical school is classroom-based mainly, with traditional chalk-and-board teaching methods (Bagot et al., 2005). At most, students participate in cadaveric dissections and human anatomy sessions such as surface anatomy courses, physiology, and biochemistry practicals in the laboratory. Students are often not introduced to clinics or patients during their first year of study. Students begin attending out-patient departments (OPD) in the second year, when the curriculum covers supportive medical disciplines such as pharmacology, pathology, and microbiology, among others, and see senior residents, lecturers, professors, and consultants assess and manage patients (Brauer & Ferguson, 2015). Educators frequently train them on patients. However, this depends on the case type and the footfall in the OPDs. In particular popular centres, the footfall is so high that it is impossible to keep patients for medical students to learn. Even though a wide range of cases is accessible in such facilities, the physicians' primary goal is to control the throng and respond to patients within the time frame set. Such facilities are also limited in space, and students cannot self-study with patients. Other centres, which are less active or do not provide the super-speciality level of management, do not have an appropriate number of attendances. The range of clinical conditions encountered would be limited as well. Educators and students must thus make the most of the few and far cases of education that are accessible (McGaghie et al., 2011).
2.2 Transition in medical education
The necessity for transition or change in the medical education system was obvious, but no shift, no matter how critical, is simple. Deliberations on the efficacy and necessity of departing from traditional medicine teaching methods, the appropriate balance of clinical and simulation learning, the topics to be covered under each, the distribution of academic hours between classroom, clinic, and simulation teaching, the timings of the three modes of education, the content for the topics, and finally, and perhaps most ambiguously, a standard, validated, and uniform method of evaluating the success of the learning experience. The transition process is challenging for educators because they must engage more time and effort in studying and preparing instructional content in accordance with the new technique. They must overcome their opposition, adapt their attitudes to their new duties, behave following their new responsibilities, and be open to new challenges and unforeseeable events. Additional expenditures such as location, people, and equipment must also be included in the proposal's budget. The global agreement is that simulation instruction results in higher efficacy as assessed by improved competence and skills outcomes. A recent study has shown a direct influence on public health outcomes, such as decreased ICU infection rates, lower delivery complications, and lower morbidity and death in the postoperative period (Barsuk et al., 2014). In a doctor's academic and professional life, there are several transition periods, such as entering medical school, transitioning from basic sciences to clinical experience, transitioning from undergraduate to post-graduation, transitioning from being a student to learning to perform at work, transitioning from junior to a senior consultant to working independently, becoming aware of recent advances, and honing lost skills. Simulation-based learning is ideal for ensuring attention and motivation and improving skills and knowledge during such transition times (Cleland et al., 2016).
2.3 Medical Education in Saudi Arabia
Y. Al-Gindan et al. (2000) identified challenges encountered by medical students and proposed improvements for medical education in Saudi Arabia. To simplify the curriculum, they suggested eliminating non-utility or unnecessary courses. They also proposed that the fundamental sciences courses be modified to be more clinically oriented. They advocated early clinical experience as part of the curriculum for this. Early clinical exposure refers to the exposure of undergraduate medical students to clinical practice during their preclinical sciences training to enrich and augment their learning experience in better knowledge of health, sickness, and patient care as healthcare professionals. Interaction with actual patients or simulation-based learning sessions combined with fundamental scientific education are examples of early clinical exposure. They also discovered that it was more beneficial to offer more community-based medical education rather than only hospital-based education since future practitioners must adhere to all working settings. Most significantly, they underlined the importance of incorporating new approaches into education to foster critical thinking and life-long learning abilities and develop appropriate values and attitudes. (Al-Gindan et al., 2000). Awdah Al-Hazimi et al. 2004.'s study comparing the performance of standard classrooms and clinic training to innovative medical schools provided much information, resulting in various modifications in the Middle East and Saudi Arabia's medical curriculum. In addition, traditional school students evaluated their learning, academic self-perceptions, social self-perceptions, teaching environment, and school atmosphere much worse than students from newer innovative schools (Al-Hazimi et al., 2004).
2.5 Early clinical exposure (ECE)
Several studies have argued for early clinical exposure (ECE) when medical students are learning preclinical sciences. Piyali Das et al. (2017) conducted a randomized control experiment on first-year MBBS physiology students. By computer selection, 150 students were randomly assigned to the study and control groups. The topic chosen was respiratory system physiology. Multiple choice questions (MCQ) and objective structured clinical examinations were used in pre- and post-classroom testing (OSCE). Before the post-test, the study group also received clinical exposure. The student t-test was used to examine the pre-test scores of both groups, the post-test scores of both groups, the pre-and post-test scores in each group separately, and the students' subjective comments. The pre-test scores of the two groups did not differ significantly. In all other cases, p<0.05 indicates that the clinical exposure that resulted in improved scores and comprehension of the issue is statistically significant. This form of instruction brought 92% of the students closer to their ultimate objective of treating patients and allowed them to use classroom learning more effectively in clinical practice. The remaining 8% said this technique was more time-consuming yet appropriate for some aspects of fundamental science (Das et al., 2017). Mafinejad et al. (2016) from the Tehran Institute of Medical Sciences confirmed these findings. They performed a survey on first and second-year undergraduate medical students using a questionnaire with open-ended questions as well as structured questions to examine their attitudes regarding early clinical experience. 80-85% of students felt favourable about this, and the reasons were grouped into three groups based on content analysis - 'integration of theory and practice', 'contact with people and professional growth' and 'desire and motivation for learning medicine'. Each of these factors is a compelling justification for better-tuned and adaptable physicians after they graduate from medical school (Khabaz Mafinejad et al., 2016). Tang et al. (2019) objectively documented these findings in their study of 109 undergraduate students at Taipei Medical University who were evaluated based on their exam scores in a systems-based introductory sciences course. The difference is that they also considered students' attitudes and degrees of anxiety about the test. Using hierarchical multiple regression (HMR) analysis, students' clinical learning time, test scores, test anxiety and motivation, and differences in clinical learning environment were all combined and evaluated. Finally, the findings demonstrated that students' test anxiety and clinical learning setting positively impacted their performance. (Tang et al., 2019).
2.6 Simulation-based medical education (SBME)
Simulation training uses various techniques, including computer-based technology with specialized trainers and life-like mannequins. It is critical to distinguish between passive low-fidelity models, such as advanced cardiac life support models, and more sophisticated high-fidelity models with dynamic airways, realistic vitals, pupillary reaction, various internal organs similar to humans, colour-coded body fluids, drug response, and allowing medical interventions such as intubation, defibrillation, and so on. The term fidelity refers to the model's similarity to the original that it is meant to imitate (Cumin & Merry, 2007). These models were initially adopted in the training of anaesthetists, which is understandable given that their employer needs them to stay aware and respond quickly to potentially life-threatening events. After numerous years, technology began to emerge. (Lampotang, 2008).
2.7 Simulation-based medical education (SBME) in undergraduate medical education
Ginzburg et al. (2017) emphasized the importance of basic sciences by conducting integrated education sessions with a small sample of first- and second-year students. They stressed that while the benefits of SBME in clinical practice have been demonstrated, studies have not reported using simulation to highlight the usefulness of fundamental scientific concepts in clinical practice. A high-fidelity simulation was conducted with small groups of first- and second-year students, followed by a debriefing session with basic science and clinical faculty members. After the session, survey-based feedback was received. The relevance of fundamental sciences in good clinical practice was emphasized by 93.8% of first-year students and 96.7% of second-year students. A clinical simulation was combined with real scientific training and was followed by debriefing helped them understand that knowledge of basic sciences is the foundation of the practice of clinical medicine.
One of the reasons for the lack of proof of the efficacy and particular results of SBME independent of other modalities of education is that simulation-related training is always included in the regular lecture schedule. Weller and colleagues (2012) Furthermore, retention and capacity to apply ideas of clinical knowledge learned during fundamental sciences study in future years after leaving medical school - sustained learning - are not adequately investigated. Schmidt and colleagues (2015) Almost all studies highlight the excellent function of SBME in ECE for students in their first year of medical school when they are generally exclusively exposed to classroom education on preclinical courses. Understandably, Lipps et al (2017) Simulation-based learning studies focus on emergency medical practice throughout undergraduate training. Evaluation of outcomes, whether objective (based on OSCE, MCQ exams, etc.) or subjective (based on students and faculty members' experiences), is usually done at the end of the study spread over a few weeks, except an occasional case where these students are evaluated, and feedback is obtained when they are in their second year of undergraduate medical education. Studies have indicated improved exam performance, retention, comprehension, knowledge, and abilities in the short term. It has also been noted that there has been an improvement in learning attitude, motivation, empathy, communication skills, and confidence. However, the final result evaluation should ideally test for knowledge and skill retention, and it makes sense to evaluate fourth or final-year students on subjects covered in SBME in the first year. The total performance of the pupils in the final examinations might also be evaluated. This will necessitate a long-term randomized control study that spans the individuals' whole undergraduate medical education period. To understand the long-term impacts of SBME and to receive essential input to enhance existing SBME programs, studies analyzing the function of SBME even after leaving medical school are necessary.
