///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-06:00

Speaking up across authority gradients: An interactive, computer-based exercise to assess long-term retention and transferability of simulator lessons

Abstract Number: 21
Abstract Type: Original Research

May C. M. Pian-Smith M.D., M.S.1 ; David J Birnbach M.D., M.P.H.2; Laura H Leduc M.D.3; Marjorie P Stiegler M.D.4; John T Sullivan M.D.5; Daniel B Raemer Ph.D.6

Introduction: Trainees should question their teachers if they disagree, have safety concerns, or when treatment plans are unclear. We determined that a simulation-based educational intervention that teaches a diplomatic "advocacy/inquiry" technique (A/I) improves the frequency and effectiveness with which residents "speak up" to superiors during simulated OB emergencies. Subsequently we seek to determine the transferability and longevity of these lessons, by testing if techniques of A/I are demonstrated by these subjects in a web computer-based exercise 2 years later.

Methods: In a simulated OR, trainees were presented with opportunities to challenge co-workers directives (eg, administer a relatively contraindicated medication). In debriefing, they were taught techniques of advocacy (saying one's observation) and inquiry (open curious request for the other's reasoning). Subjects participated in another scenario at that time with new opportunities to challenge. In this ongoing work, consented subjects are followed-up 2 years later and are asked to view video vignettes on a website. An anesthesiologist in the movies asks them to do things that are controversial (eg, place a spinal in a septic patient; give nalbuphene to a patient on methadone). Their real-time spontaneous responses are audio-taped. They each view 4 videos and have 2 opportunities to "speak up" during each case. As with the initial intervention, language is rated on a 5-pt scale (1: no acknowledgement of problem; 2: oblique answer; 3: A or I; 4: A and/or I repeatedly with desire for discussion; 5: crisp succinct A/I ). A control group (trainees and junior staff experienced with simulation but who have not been trained specifically about A/I, from the Feinberg SOM at Northwestern, Geffen SOM at UCLA and Miller SOM at Miami) is also being studied.

Results: Mean scores for the original subjects were statistically different, pre- and post-debriefing (2.3 +/- 1.3 vs 3.6 +/- 1.2). Fourteen subjects (of a projected cohort of 40) have completed the follow-up study so far. In the on-going follow-up study, the mean time interval between initial training and follow-up is 24 +/- 4.9 months, and the mean language score for challenging is 3.0 +/- 1.4. Results from the control group are pending.

Discussion: An immersive simulation program improved "speaking up" by residents across authority gradients during simulated OB emergencies. We are assessing long-term retention and transferability of such simulation lessons with a computer-based exercise 2 years later by comparing the results with those from nave controls. Ultimately, overcoming communication barriers within the medical hierarchy may improve learning opportunities and promote patient safety.

Reference: Pian-Smith M, Simon R, Minehart R, Podraza M, Rudolph J, Walzer T, Raemer D. Teaching Residents the Two-Challenge Rule: A Simulation-based Approach to Improve Education and Patient Safety. Simulation in Healthcare. In press

SOAP 2009