Objectives This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit. Methods This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969-2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003-2009. Results The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record. Conclusions Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts. Medical Education 2010: 44: 50-63.
Context Cognitive load theory aims to develop instructional design guidelines based on a model of human cognitive architecture. The architecture assumes a limited working memory and an unlimited long-term memory holding cognitive schemas; expertise exclusively comes from knowledge stored as schemas in long-term memory. Learning is described as the construction and automation of such schemas. Three types of cognitive load are distinguished: intrinsic load is a direct function of the complexity of the performed task and the expertise of the learner; extraneous load is a result of superfluous processes that do not directly contribute to learning, and germane load is caused by learning processes that deal with intrinsic cognitive load. Objectives This paper discusses design guidelines that will decrease extraneous load, manage intrinsic load and optimise germane load. Discussion Fifteen design guidelines are discussed. Extraneous load can be reduced by the use of goal-free tasks, worked examples and completion tasks, by integrating different sources of information, using multiple modalities, and by reducing redundancy. Intrinsic load can be managed by simple-to-complex ordering of learning tasks and working from low- to high-fidelity environments. Germane load can be optimised by increasing variability over tasks, applying contextual interference, and evoking self-explanation. The guidelines are also related to the expertise reversal effect, indicating that design guidelines for novice learners are different from guidelines for more experienced learners. Thus, well-designed instruction for novice learners is different from instruction for more experienced learners. Applications in health professional education and current research lines are discussed. Medical Education 2010: 44: 85-93.
Medical Education 2012 Context High‐fidelity simulators have enjoyed increasing popularity despite costs that may approach six figures. This is justified on the basis that simulators have been shown to result in large learning gains that may transfer to actual patient care situations. However, most commonly, learning from a simulator is compared with learning in a ‘no‐intervention’ control group. This fails to clarify the relationship between simulator fidelity and learning, and whether comparable gains might be achieved at substantially lower cost. Objectives This analysis was conducted to review studies that compare learning from high‐fidelity simulation (HFS) with learning from low‐fidelity simulation (LFS) based on measures of clinical performance. Methods Using a variety of search strategies, a total of 24 studies contrasting HFS and LFS and including some measure of performance were located. These studies referred to learning in three areas: auscultation skills; surgical techniques, and complex management skills such as cardiac resuscitation. Results Both HFS and LFS learning resulted in consistent improvements in performance in comparisons with no‐intervention control groups. However, nearly all the studies showed no significant advantage of HFS over LFS, with average differences ranging from 1% to 2%. Discussion The factors influencing learning, and the reasons for this surprising finding, are discussed. Discuss ideas arising from this article at ‘’
Medical Education 2012: 46: 58–70 Context Interprofessional education (IPE) is not a recent phenomenon and has been the subject of several World Health Organization reports. Its focus is on health professionals and students learning with, from and about one another to improve collaboration and the quality of patient care. The drivers for IPE include new models of health care delivery in the context of an ageing population and the increasing prevalence of long‐term chronic disease, in addition to the patient safety agenda. The delivery of complex health care requires a team‐based and collaborative approach, although teamwork and collaborative practice are not necessarily synonymous. The rationale for IPE is that learning together enhances future working together. Discussion Systematic reviews of IPE have shown some evidence that IPE fosters positive interaction among different professions and variable evidence that it improves attitudes towards other professionals. Generalisation across published papers is difficult because IPE initiatives are diverse and good evaluation methodology and data are lacking. In terms of constructive alignment from an education viewpoint, there is a need for educators to define learning outcomes and match these with learning activities to ensure that IPE demonstrates added value over uniprofessional learning. Assessment is difficult as pre‐qualification professional education focuses on the individual and professional accreditation organisations mandate only for their own professions. Conclusions Interprofessional education draws from a number of education, sociology and psychology theories, and these are briefly discussed. The most pressing research questions for the IPE community are defined and the challenges for IPE explored.
Medical Education 2011: 45 : 792–806 Objectives In this review, we portray the process of problem‐based learning (PBL) as a cognitive endeavour whereby the learner constructs mental models relevant to problems. Two hypotheses are proposed to explain how learning is driven in PBL; an activation–elaboration hypothesis and a situational interest hypothesis. Methods Research relevant to these hypotheses is discussed. In addition, research studying the effects of various support strategies used in PBL is reviewed. Finally, we summarise a number of recent studies in which a new ‘micro‐analytical’ methodology was used to trace the process of PBL in the natural classroom setting. Conclusions We conclude that there is considerable support for the idea that PBL works because it encourages the activation of prior knowledge in the small‐group setting and provides opportunities for elaboration on that knowledge. These activities facilitate the comprehension of new information related to the problem and enhance its long‐term memorability. In addition, there is evidence that problems arouse situational interest that drives learning. Flexible scaffolding provided by cognitively and socially congruent tutors also seems to be reasonably effective, as opposed to ‘hard’ scaffolding represented by, for instance, worksheets or questions added to problems. Small‐group work protects against dropout and encourages students to study regularly. Initially, students do not study much beyond the learning issues generated; the development of personal agency in self‐study needs time to develop. The extent of learning in PBL results from neither group collaboration only (the social constructivist point of view) nor individual knowledge acquisition only; both activities contribute equally to learning in PBL.
Objectives Findings from the contemporary psychological and movement science literature that appear to have implications for medical training are reviewed. Specifically, the review focuses on four factors that have been shown to enhance the learning of motor skills: observational practice; the learner's focus of attention; feedback, and self-controlled practice. Observational Practice Observation of others, particularly when it is combined with physical practice, can make important contributions to learning. This includes dyad practice (i.e. practice in pairs), which is not only cost-effective, but can also enhance learning. Focus of Attention Studies examining the role of the performer's focus of attention have consistently demonstrated that instructions inducing an external focus (directed at the movement effect) are more effective than those promoting an internal focus (directed at the performer's body movements). An external focus facilitates automaticity in motor control and promotes movement efficiency. Feedback Feedback not only has an informational function, but also has motivational properties that have an important influence on learning. For example, feedback after successful trials and social-comparative (normative) feedback indicating better than average performance have been shown to have a beneficial effect on learning. Self-Controlled Practice Self-controlled practice, including feedback and model demonstrations controlled by the learner, has been found to be more effective than externally controlled practice conditions. Conclusions All factors reviewed in this article appear to have both informational and motivational influences on learning. The findings seem to reflect general learning principles and are assumed to have relatively broad applicability. Therefore, the consideration of these factors in designing procedures for medical training has the potential to enhance the effectiveness and efficiency of training. Medical Education 2010: 44: 75-84.
Background Effective feedback may be defined as feedback in which information about previous performance is used to promote positive and desirable development. This can be challenging as educators must acknowledge the psychosocial needs of the recipient while ensuring that feedback is both honest and accurate. Current feedback models remain reductionist in their approach. They are embedded in the hierarchical, diagnostic endeavours of the health professions. Even when it acknowledges the importance of two-way interactions, feedback often remains an educator-driven, one-way process. Lessons from the Literature An understanding of the various types of feedback and an ability to actively seek an appropriate approach may support feedback effectiveness. Facilitative rather than directive feedback enhances learning for high achievers. High-achieving recipients undertaking complex tasks may benefit from delayed feedback. It is hypothesised that such learners are supported by reducing interruptions during the task. If we accept that medical students and doctors are high achievers, we can draw on some guiding principles from a complex and rarely conclusive literature. Feedback should focus on the task rather than the individual and should be specific. It should be directly linked to personal goals. Self-assessment as a means to identify personal learning requirements has no theoretical basis. Motivated recipients benefit from challenging facilitated feedback from external sources. A New Model To achieve truly effective feedback, the health professions must nurture recipient reflection-in-action. This builds on self-monitoring informed by external feedback. An integrated approach must be developed to support a feedback culture. Early training and experience such as peer feedback may over time support the required cultural change. Opportunities to provide feedback must not be missed, including those to impart potentially powerful feedback from high-stakes assessments. Feedback must be conceptualised as a supported sequential process rather than a series of unrelated events. Only this sustained approach will maximise any effect. Medical Education 2010: 44: 101-108.
Medical Education 2011: 45 : 60–68 Context Pedagogical practices reflect theoretical perspectives and beliefs that people hold about learning. Perspectives on learning are important because they influence almost all decisions about curriculum, teaching and assessment. Since Flexner’s 1910 report on medical education, significant changes in perspective have been evident. Yet calls for major reform of medical education may require a broader conceptualisation of the educational process. Past and current perspectives Medical education has emerged as a complex transformative process of socialisation into the culture and profession of medicine. Theory and research, in medical education and other fields, have contributed important understanding. Learning theories arising from behaviourist, cognitivist, humanist and social learning traditions have guided improvements in curriculum design and instruction, understanding of memory, expertise and clinical decision making, and self‐directed learning approaches. Although these remain useful, additional perspectives which recognise the complexity of education that effectively fosters the development of knowledge, skills and professional identity are needed. Future perspectives Socio‐cultural learning theories, particularly situated learning, and communities of practice offer a useful theoretical perspective. They view learning as intimately tied to context and occurring through participation and active engagement in the activities of the community. Legitimate peripheral participation describes learners’ entry into the community. As learners gain skill, they assume more responsibility and move more centrally. The community, and the people and artefacts within it, are all resources for learning. Learning is both collective and individual. Social cognitive theory offers a complementary perspective on individual learning. Situated learning allows the incorporation of other learning perspectives and includes workplace learning and experiential learning. Viewing medical education through the lens of situated learning suggests teaching and learning approaches that maximise participation and build on community processes to enhance both collective and individual learning.
Background Interviews are among the most familiar strategies for collecting qualitative data. The different qualitative interviewing strategies in common use emerged from diverse disciplinary perspectives resulting in a wide variation among interviewing approaches. Unlike the highly structured survey interviews and questionnaires used in epidemiology and most health services research, we examine less structured interview strategies in which the person interviewed is more a participant in meaning making than a conduit from which information is retrieved. Purpose In this article we briefly review the more common qualitative interview methods and then focus on the widely used individual face‐to‐face in‐depth interview, which seeks to foster learning about individual experiences and perspectives on a given set of issues. We discuss methods for conducting in‐depth interviews and consider relevant ethical issues with particular regard to the rights and protection of the participants.
The opposing forces of increased training expectations and reduced training resources have greatly impacted health professions education. Virtual patients (VPs), which take the form of interactive computer-based clinical scenarios, may help to reconcile this paradox. We summarise research on VPs, highlight the spectrum of potential variation and identify an agenda for future research. We also critically consider the role of VPs in the educational armamentarium. We propose that VPs' most unique and cost-effective function is to facilitate and assess the development of clinical reasoning. Clinical reasoning in experts involves a non-analytical process that matures through deliberate practice with multiple and varied clinical cases. Virtual patients are ideally suited to this task. Virtual patients can also be used in learner assessment, but scoring rubrics should emphasise non-analytical clinical reasoning rather than completeness of information or algorithmic approaches. Potential variations in VP design are practically limitless, yet few studies have rigorously explored design issues. More research is needed to inform instructional design and curricular integration. Virtual patients should be designed and used to promote clinical reasoning skills. More research is needed to inform how to effectively use VPs.
Medical Education 2012: 46 : 1028–1041 Context Longitudinal integrated clerkships (LICs) have been widely implemented in both rural and urban contexts, as is now evident in the wealth of studies published internationally. This narrative literature review aims to summarise current evidence regarding the outcomes of LICs for student, clinician and community stakeholders. Methods Recent literature was examined for original research articles pertaining to outcomes of LICs. Results Students in LICs achieve academic results equivalent to and in some cases better than those of their counterparts who receive clinical education in block rotations. Students in LICs are reported to have well‐developed patient‐centred communication skills, demonstrate understanding of the psychosocial contributions to medicine, and report more preparedness in higher‐order clinical and cognitive skills in comparison with students in traditional block rotations (TBRs). Students in LICs take on increased responsibility with patients and describe having more confidence in dealing with ethical dilemmas. Continuity of supervision reportedly facilitates incremental knowledge acquisition, and supervisors provide incrementally progressive feedback. Despite early disorientation regarding the organising of their learning, students feel well supported by the continuity of student–preceptor relationships and value the contributions made by these. Students in LICs living and working in rural areas are positively influenced towards primary care and rural career choices. Discussion A sound body of knowledge in the field of LIC research suggests it is time to move beyond descriptive or exploratory research that is designed to justify this new educational approach by comparing academic results. As the attributes of LIC alumni are better understood, it is important to conduct explanatory research to develop a more complete understanding of these findings and a foundation for new theoretical frameworks that underpin educational change. Conclusions Longitudinal integrated clerkships are now recognised as representing credible and effective pedagogical alternatives to TBRs in medical education. Discuss ideas arising from this article at ‘discuss’
Context There are inconsistent claims made about the effectiveness of the flipped classroom (FC) in medical education; however, the quality of the empirical evidence used to back up these claims is not evident. The aims of this review are to examine the scope and quality of studies on the FC teaching approach in medical education and to assess the effects of FCs on medical learning. Methods A literature search was conducted using the major electronic databases in 2016. Peer-reviewed papers were screened and reviewed according to explicit inclusion criteria. The scope and quality of all resultant studies were evaluated. Studies identified as using controlled designs were further synthesised to assess the effects of FCs on learning. Results A total of 118 articles were obtained. Full texts of 82 articles were reviewed. Nine of the included 46 articles used a controlled design when examining the effects of the FC. There were generally positive perceptions of the FC approach. However, the effects of FCs on changes in knowledge and skills were less conclusive as the effect sizes ranged from d = -0.27 to 1.21, with a median of 0.08. The varying direction and magnitude of the effect sizes, together with their 95% confidence interval, which contained zero, suggested the lack of strong evidence for the effectiveness of FCs in promoting knowledge acquisition above and beyond the traditional learning methods. Conclusions There has been a recent increase of research rigor and variety in measures of effectiveness in studies on the FC in medical education. The FC is a promising teaching approach to increase learners' motivation and engagement. More solid evidence on its effect on changes in knowledge and skills are warranted. Further studies should also examine the long-term effects of FCs with regard to knowledge retention and transfer of knowledge to professional practice and patient care.