ABSTRACT
Doctors are required to be able to care for patients in a variety of settings, including the patient’s home. Patients requiring urgent care in their own homes are at risk of acute deterioration. However, differentiating acute deterioration from self-limiting conditions in the primary care environment can be challenging, even for GPs who are experienced in managing clinical uncertainty and ambiguity. Preparedness for practice of foundation doctors is directly related to opportunities for experiential learning and medical students face many barriers to obtaining experience of acute care in clinical environments. Simulation has been used in healthcare education as an adjunct to experiential learning in clinical environments since the 1950s. At present, the utilisation of immersive simulation in primary care environments for medical students is uncommon even though many foundation doctors will work in primary care. This article describes how faculty at a UK medical school developed an immersive simulated home visit scenario on an ‘Acute Care Course’ for medical students during their Assistantship. Debriefing discussions between students, faculty, and simulated participants focused on the cognitive, emotional, and ethical impacts of uncertainty and how this influenced clinical decision-making for medical students. Having an authentic simulated scenario in the primary care environment, where clinical uncertainty and ambiguity are ubiquitous, offered students opportunities in experiential learning in how to make clinical decisions, despite clinical uncertainty and ambiguity, when assessing and caring for acutely unwell patients.
Introduction
‘Medicine is a science of uncertainty and the art of probability.’
Osler (Bean and Bean, 1950) [Citation1]
The ability to recognise acutely unwell patients and initiate a timely management plan is an essential skill for all doctors, including newly qualified foundation doctors [Citation2]. Clinical situations involving acutely unwell patients are inherently associated with clinical uncertainty and ambiguity due to the initial undifferentiated, rapidly evolving and time critical nature of acute illness. Clinical uncertainty describes situations where knowledge or understanding is insufficient to allow for confident clinical decision-making; ambiguity describes situations where multiple clinical choices appear equally reasonable [Citation3]. Clinical uncertainty and ambiguity are ubiquitous in primary care with most diagnoses being elusive at the time of presentation [Citation4]. It is unknown what proportion of patient contacts in primary care are because of an acute deterioration, but the prevalence is significantly lower when compared to secondary care settings [Citation5]. However, patients being assessed in their own homes are more at risk of acute deterioration as they are considerably older, have less physiological reserve, and have more complex medical needs [Citation5] and differentiating between serious acute deteriorations and minor self-limiting conditions is particularly challenging in patients with long-term conditions [Citation5,Citation6]. Moreover, our ageing population and shift of healthcare from primary to secondary care, will further intensify the presentation of patients with acute illness in the community.
Acute deterioration has been defined as, ‘an evolving, predictable and symptomatic process of worsening physiology towards critical illness’ [Citation7]. Managing acutely deteriorating patients requires the ability to process information quickly with ‘multitude of inputs, roles and demands that require situated cognition’ [Citation8]. All doctors, foundation doctors included, must be able to holistically assess acutely unwell patients and manage acute undifferentiated, emerging illness and its associated risk. Prompt recognition of clinical deterioration, either due to acute illness or acutely decompensated chronic illness, allows for timely escalation to appropriate care and improved patient experiences and outcomes.
Medical students transitioning to foundation doctors quite often experience gaps in their acute care experience resulting in a reduction in their perceived preparedness in this area [Citation9–11]. Evidence shows that preparedness for practice is directly related to experiential learning and has prompted the creation of student assistantships [Citation12,Citation13]. Student assistantships were introduced in 2009 following a recommendation by the GMC as clinical placements in which senior medical students assist junior doctors, and under supervision undertake most of the duties of a foundation doctor, i.e. a clinical placement to bridge the gap between medical student and doctor [Citation14].
Despite the creation of medical student assistantships, it remains challenging to ensure that all medical students have suitable experience of acute care. These challenges are varied: the ‘competition’ for acute care experience between healthcare students and trainees, the unpredictable nature of acute care, the low prevalence of specific medical emergencies, and society’s understandable expectation of patient safety [Citation9]. The current healthcare culture of patient safety, with its zero-tolerance for medical error causes significant tensions between education and clinical service delivery [Citation15]. Some clinical educators, especially those with less experience, may find it difficult to fully entrust healthcare students and healthcare trainees to actively contribute to patient care [Citation16]. Barriers to experiential learning via active participation in patient care hinders the graduated transition to independent practice for healthcare students and trainees.
A role for simulation in primary care for developing skills in managing uncertainty?
Simulation-based education (SBE) is used as a tool for experiential learning in many hospital specialities to teach cognitive, psychomotor, and affective skills to individuals and teams and thus can aid the graduated transition to independent practice [Citation17]. Simulation in primary care, though not a tradition, is gaining traction [Citation18–21]. Innovations in SBE, such as simulation in primary care, present new opportunities to enhance healthcare education and patient care [Citation22]. An authentic simulated scenario was designed for final-year medical students during assistantship to offer opportunities to gain experience in clinical decision-making when there is clinical uncertainty or ambiguity. The primary care environment is ripe with opportunities for medical students to acquire and develop situated cognition when dealing with clinical uncertainty or ambiguity. The ‘home visit’ scenario was designed so medical students could be offered experiential learning in rapidly evolving high-acuity acute care situations that require them to consider the decision-making process required of their future professional selves.
The acute care course
In this section we will give a brief overview of the Acute Care Course (ACC) to provide the context for the innovative development of a primary care simulation within the course.
The ACC sits within the Assistantship Module in final year for undergraduate medical students in Queen’s University, Belfast, and students on the course in 2020/2021 also had opportunity to acquire eALS certification. Previous iterations of the ACC focused solely on acute care in the hospital environment. The university has responded to society’s changing patient needs with a new curriculum. The C25 curriculum consists of an integrated systems-based approach with longitudinal integrated clerkships in which primary care placements comprise one-quarter of all clinical placements. There is a growing recognition in the medical education community of the importance of teaching generalism and promoting General Practice to the future workforce [Citation23]. The new ACC was pragmatically adapted from previous forms designed with the features of SBE and these wider elements in mind. provides a brief overview of the considerations given to the educational practice components of the ACC and provides a brief overview of the ‘Simulation Cycle’ on which this course was based upon.
Figure 1. Simulation cycle used to design the ACC and the ‘home visit’ scenario.
Table 1. Acute care course design overview.
The ACC was mandatory for final-year students and consisted of a circuit with eight stations. Students were in groups of seven and rotated around all simulated scenarios (i.e. status epilepticus, massive haemorrhage, escalation of care in a patient with respiratory failure, atrial fibrillation, acute pulmonary oedema and the home visit) and advanced clinical skills (i.e. nasogastric tube insertion, hyperkalaemia, oxygen delivery devices and tracheostomy care). Each station had a specific focus on acute, critical and emergency care. Students were encouraged to self-nominate as a lead or co-lead in at least one simulated scenario. A mixture of hospital doctors and general practitioners facilitated the course and were supported by a simulation technician and the administrative professionals. All faculty involved in the delivery of the course attended a faculty orientation and briefing session. Staff were provided with information on the logistics of, aims and objectives for, and the teaching and learning methods to be employed within the course during this pre-briefing session. Faculty at Queen’s are also offered training on effective debriefing in simulation-related practice on a half-day debriefing course. All resources for the advanced clinical skills and simulated scenarios were made accessible to all facilitators online. The ACC took place in a purpose-built suite called InterSim that was created for multi-professional clinical education skills education at Queen’s University, Belfast.
The simulated home visit scenario of an acutely unwell patient
In this section we will provide a detailed overview of the simulated ‘home visit’ scenario ().
Figure 2. Image illustrating a simulation home visit of an acutely unwell patient and a connected conversation suite used for observation and debriefing.
Pre-brief: setting the scene
Students initially gathered in a large room with audio-visual technology suitable for small group discussions. The intention of scenario, exploring students’ decision-making during clinical uncertainty or ambiguity, was discussed with the students during the pre-brief. Two students nominated themselves as foundation doctors who would carry out the home visit. A ‘Doctor’s Bag’ was provided stocked with usual on-call GP resources. The student-pair walked to the home visit room and remaining students watched the simulated consultation on screen. The clinical facilitator went with the student-pair and offered information such as vital signs. Students often used the time during the walk to discuss how they would approach the assessment and potential management decisions. All students were encouraged to participate in the debrief discussions together in a constructive manner following the scenario.
The simulated scenario
The patient is an 86-year-old who is living independently in a supported-living complex. They have a history of mild cognitive impairment and have called the warden this morning for help to get up after a fall. The patient is unable to give a clear history of events but mentions some urinary symptoms and hip pain. Urinalysis is positive for leucocytes and the patient can weight bear. There is poor lighting, and the room is cluttered. Medications on the bedside are slightly different to those listed on the medication history in the GP records. A daughter is due to visit in several days.
What worked and how?
The new InterSim at Queen’s was an ideal facility for the ACC as it allowed scenarios to be set in simulated clinical environments (wards and a home environment) thus creating an immersive simulated experience for students. Conversation suites are furnished with plectrum-shaped tables which encouraged active and collaborative learning due to their shape (which reduces power differentials between facilitators and students). Conversation suites have audio-visual connections to the simulated clinical environments. This permitted the indirect observation of students who led the simulated scenario and enhanced the psychological safety of those students being observed. Despite our utilisation of these conducive facilities and technological resources on the ACC, they are not essential to creating an immersive simulation in a home environment: recording a student-led simulated consultation in an adapted area on an iPad could create a similar learning opportunity.
Academic Foundation trainees were involved in the creation, road testing of simulated scenarios, and facilitation of the ACC. This utilisation of near-peer teachers promoted the engagement of final year students. Some stations in the ACC were outcome-based skills stations with clearly measurable competencies e.g. NGT insertion. In such stations, students were afforded time for individual deliberate practice of advanced clinical skills not previously covered in eALS.
Facilitators used the PEARLS [Citation24] and Diamond Debrief [Citation25] models to debrief with students and simulated participants often contributed to the debrief discussions. Although each debrief was unique to the group of individuals contributing, common themes emerged. The use of these debriefing models ensured a learner-centred approach whilst ensuring that facilitators could highlight key learning points if appropriate e.g. updated guidelines or outcomes for graduates.
The ’home visit’ scenario placed an emphasis on optimising students’ learning through reflection and dialogue rather than measuring specific outputs or outcomes. Placing the emphasis on optimising students’ learning rather than measuring outputs or outcomes, supported students to develop metacognitive habits by encouraging students to reflect on how and why they made the decisions they made. The scenario was a stimulus for dialogue on managing and navigating uncertainty in complex healthcare systems. Learner-centred debriefing discussions encouraged students to think contextually and reflect on how patients’ preferences, values and expectations may create tensions for the clinician. Students considered the cognitive, emotional, and ethical aspects of uncertainty and how their own threshold of acceptable risk could impact on decisions about patient care. There were many ‘lightbulb’ moments when students reflected on how decisions to refer for further investigations, such as plain imaging, were influenced significantly by the discomfort that they experienced whilst ‘holding the risk’ associated with clinical uncertainty. Students reflected how a dynamic, reiterative, and person-centred approach with due regard to diagnostic probability may help to ‘share the risk’ with the patient, their family, and carers.
Students considered the cultural context in which clinical uncertainty takes place and how patient safety frameworks within healthcare may encourage the pursuit of a definite diagnosis through investigation without due consideration of whether a diagnosis should be confirmed or what impact a definite diagnosis would have on patient care. Students considered the costs of reducing uncertainty through investigation in terms of risk of harm to patients when referred to secondary care settings e.g. nosocomial infections and isolation (especially relevant during a global pandemic) and on healthcare resources i.e. high-value versus low-value healthcare.
Students considered the importance of effectively utilising the multidisciplinary team when providing acute care for a patient in their home environment and explorative discussions took place regarding how teams such as Acute Care at Home, community pharmacy, district nursing and social services can be accessed and co-ordinated via primary care to provide bespoke, safe, urgent care to a patient in their home environment. Students also reflected on how patients may, despite these resources, still require admission to hospital for acute care, and how clinicians and patients will have navigated a complex decision-making process together to reach that conclusion. It was an opportunity to reflect on the skills and expertise of primary care teams managing complex clinical situations in the community.
Simulated participants quite often brought their own lived experiences of urgent healthcare to the debrief discussions that enriched the learning environment for all participants.
Student feedback
In this section we will provide a brief overview of the impact of the ACC and ‘home visit’ scenario on medical students based upon feedback received.
Ninety-four per cent of students either agreed or strongly agreed that the ACC had enhanced their knowledge, skills, and behaviour in the care of the acutely unwell patient in any setting. Students valued the opportunity to gain experiential learning opportunities in the assessment and care of patients who were acutely unwell and recognised the added complexities when assessing someone with undifferentiated illness in their own home. Using IT effectively in the home visit scenario added to the ‘psychological safety’ experienced by students.
‘Wide range of acute scenarios that made us think (rather than just following algorithms)’
‘ … feel more prepared for acute scenarios in real life … ’
‘Very interactive day, learnt a lot of practical skills and got the opportunity to engage in more complicated scenarios’.
‘Great learning experience. Opportunity to apply knowledge. Ability to practice emergency scenarios for the first time before starting foundation years’.
‘The home visit scenario was excellent, and it was nice to not have to perform in front of your peers so reduced my nerves for this station’.
‘These are all pretty complex stations and ones we don’t really get very much teaching on and are difficult to catch in the wards despite full attendance’.
Conclusion
Authentic, immersive simulation can be utilised to provide opportunities for senior medical students to enhance their knowledge, psychomotor and behavioural skills in the care of patients who are acutely unwell. The ‘home visit’ scenario provided an opportunity for medical students to have individual cognitive deliberate practice in diagnostic and management reasoning when facing clinical uncertainty. Utilising the simulated primary care environment was ideal for senior medical students to develop situated cognition when considering how to approach the assessment and management of someone who is acutely unwell. Senior medical students learnt about the impact of clinical uncertainty on patients, themselves, and healthcare systems and about the resources that can be utilised in the primary care environment when caring for a patient who is acutely unwell. It offered an opportunity to reflect on the complex decision-making process that has taken place between a patient and primary care teams prior to any potential referral to secondary care and what it feels like to make that decision; it’s an opportunity that students recognise as being difficult ‘to catch in the wards’.
Debriefing discussions in a psychologically safe environment encouraged transformative learning and SBE is a useful adjunct to the clinical placements during assistantship to enhance the preparedness of medical students as they transition to foundation doctors. The authors would encourage others to consider the use of the primary care environment in SBE as a rich learning experience in decision-making when there is uncertainty or ambiguity for senior medical students as they transition to foundation doctors.
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References
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