Enhancing UK Core Medical Training

through simulation-based education:

an evidence-based approach
A report from the joint JRCPTB/HEE Expert Group
on Simulation in Core Medical Training

October 2016
 Acknowledgements
The Joint Royal Colleges of Physicians Training Board (JRCPTB) improves
patient care by setting and maintaining standards for the highest quality of
physician training in the UK on behalf of the Royal College of Physicians of
London (RCPL), the Royal College of Physicians of Edinburgh (RCPE) and the
Royal College of Physicians and Surgeons of Glasgow (RCPSG). It achieves
this through excellence in curriculum design and implementation, providing
oversight of the recruitment and certification of trainees and by supporting
the General Medical Council (GMC) in quality management.

Health Education England (HEE) is responsible for delivering a better health

and healthcare workforce for England. It is the organisation responsible for
the education, training and personal development of every member of staff,
and recruiting for values.

This report was prepared under the oversight of the joint JRCPTB/HEE Expert Group
on Simulation in Core Medical Training (CMT). A list of Group members is provided
as Appendix 1. Names and titles were accurate as per the last meeting of the Group.

The Group would like to particularly thank the following for their contributions:

Principal authors:

Dr Makani Purva, Director of Simulation and Deputy Chief Medical Officer, Hull and
East Yorkshire Hospitals NHS Trust (formerly Director of Medical Education, Hull and
East Yorkshire Hospitals NHS Trust)

Dr Graham Fent, Specialty Registrar in Cardiology, Health Education Yorkshire

and the Humber (formerly Educational Leadership in Simulation Fellow, School of
Medicine, Health Education Yorkshire and the Humber)

Dr Anoop Prakash, Consultant in Respiratory Medicine, Hull and East Yorkshire

Hospitals NHS Trust (formerly Educational Leadership in Simulation Fellow, School of
Medicine, Health Education Yorkshire and the Humber)

Principal editor:

Dr Miriam Armstrong, Senior Policy Adviser, JRCPTB

Survey of UK CMT Training Programme Directors (TPDs):

Professor Jean Ker, NHS Education for Scotland (NES) National Clinical Lead for Skills
and Simulation; Associate Dean of Innovation and Medical Education, Ninewells
Hospital and Medical School, Dundee

Dr Nicki Colledge, Director of Education, Royal College of Physicians Edinburgh (RCPE)

2
Executive summary
Simulation-based education (SBE) is increasingly becoming a vital component of postgraduate
medical education. Its adoption is supported by national policies and an expanding body
of literature. Although pioneered in anaesthetics and surgical training in the UK, SBE is an
important element of physician training that is widely recognised as a means of improving
patient outcomes through enhanced learning of evidence-based standards.

The Joint Royal Colleges of Physicians Training Board (JRCPTB) and Health Education England (HEE) are
committed to harnessing faculty and technology to support the development of excellence in education
and to driving up the quality of Core Medical Training (CMT). CMT has been a shared priority for some
time and this report reflects the importance assigned to achieving those aims, but with improvements
underpinned by an evidence base.

The recommendations in this document are based on a detailed review of the literature and expert
opinion on best practice. It examines those aspects of the CMT curriculum that can be appropriately
and effectively taught using SBE and provides recommendations for their mandatory implementation.
The findings are intended to assist Training Programme Directors (TPDs), Heads of Schools of Medicine,
Foundation Schools, Deaneries, Local Offices of HEE, consultants and everyone else involved with the
delivery of CMT, in understanding exactly how and where simulation can be used most effectively to
improve educational outcomes and trainee experience.
3
The key findings are as follows:

• There is good evidence (T3)1 that certain CMT practical procedures (central venous catheterisation,
thoracentesis, abdominal paracentesis) and emergency presentations (cardiorespiratory arrest) can
improve patient outcomes if taught using SBE. There is no obvious reason why additional CMT
procedures should not also be taught using SBE, indeed the evidence points to it being desirable
to do so

• There is reasonable evidence (T2) that non-technical and human factors skills required by CMT can be
effectively taught using SBE

• The teaching of CMT essential and desirable procedures (see Appendix 2 for more details) and
also non-technical skills using SBE is already widespread within the UK and CMT TPDs support this
training.

The JRCPTB intends to submit a revised CMT curriculum to the General Medical Council (GMC) based on
these findings, and which proposes:

That all essential and desirable practical procedures listed in the CMT curriculum should
be taught by simulation as early as possible in Year One, with further simulation teaching
involving human factors and scenarios training carried out in either Year One or Year Two.
The latter should also include refresher training for procedural skills where necessary.

The supporting evidence for this action, plus additional recommendations, is discussed in the main
report. It should be noted that all different types of SBE can be used to achieve the required learning
outcomes. Examples include (but are not limited to) task training, manikin-based simulation, standardised
patient approaches or virtual reality. This is subject to the availability of equipment and faculty.

1 The relative strength of evidence has been graded according to the system commonly used for medical educational outcomes.
In this instance, T1 level evidence is where an effect is demonstrated in the simulation centre, T2 is where an effect on
downstream patient care behaviours and practices is demonstrated and T3 is where an effect attributable to simulation on
patient care or public health is demonstrated. More details are provided in the Methodology section.

4
Contents

Acknowledgements.................................................................................................2
Executive summary..................................................................................................3
Contents..................................................................................................................5
Foreword.................................................................................................................6
Introduction.............................................................................................................7
Methodology...........................................................................................................9
1) Literature review.................................................................................................9
2) Survey of CMT Training Programme Directors (TPDs).........................................10
Results...................................................................................................................11
1) Literature review...............................................................................................11
2) Survey of CMT Training Programme Directors (TPDs).........................................13
Discussion..............................................................................................................16
Recommendations.................................................................................................18
Conclusion.............................................................................................................21
References.............................................................................................................23
Appendix 1 — Membership of the joint JRCPTB/HEE Expert Group
on Simulation in Core Medical Training .................................................................26
Appendix 2 — Procedural competencies for CMT..................................................28
Appendix 3 — UK CMT Training Programme Director (TPD) web-based survey.......30
Appendix 4 — Details from key references identified from the literature search......33

5
Foreword
Recent years have seen a widespread rise in the adoption of simulation-based education (SBE)
amongst postgraduate specialties, supported by an ever-expanding body of literature. Although
initially pioneered in anaesthetics and surgical training in the UK, SBE is increasingly recognised
as an important element of physician training. It is effective in improving patient safety and care,
as well as enhancing learning, and is being more widely embedded in both undergraduate and
postgraduate training programmes.

As partner organisations for this report, the Joint Royal Colleges of Physicians Training Board (JRCPTB)
and Health Education England (HEE) are committed to expanding the use of SBE to contribute to
excellence in the training and development of healthcare staff. Core Medical Training (CMT) has been
a shared priority for both organisations for some time and this report reflects the importance assigned
to driving up the quality of CMT as quickly as possible, but with the proposed improvements being
underpinned by an evidence base.

Drawing on the experience of the joint JRCPTB/HEE Expert Group on Simulation in CMT, this document
identifies those aspects of the CMT curriculum which can be appropriately taught using SBE and provides
recommendations as to when implementation should be mandatory.

The recommendations are based on a detailed review of the literature (pertaining to the syllabus contents
of the CMT curriculum) and expert opinion on best practice. They are expected to be fully implemented
by Training Programme Directors (TPDs), Heads of Schools of Medicine, consultants and all educators
involved in the delivery of CMT.

The recommendations will also be of relevance to those responsible for implementation of the JRCPTB’s
CMT quality criteria2 (2015), one of which is dedicated to the use of SBE:

B.4 Skills laboratory and/or simulation training for all mandatory procedural skills to be provided at least
once a year to supplement clinical training.

This document is intended to promote the wider adoption of SBE as early as possible within UK CMT to
improve the quality of training for better patient care. It will also help those overseeing the delivery of
training identify exactly how and where learning can be enhanced via the use of simulation and meet the
requirements of the CMT quality criteria in the process.

Professor David Black Alan Ryan

Medical Director, JRCPTB Director of National Programmes, HEE

2 For more details see: http://www.jrcptb.org.uk/quality-criteria-core-medical-training

6
Introduction
Overarching policy context

The value of simulation-based education (SBE) to postgraduate medical education and training has
been evident for some time. The report 150 years of the Annual Report of the Chief Medical Officer:
On the state of public health 2008 (Department of Health, 2009) provided the impetus for the growth
of simulation in the UK and suggested that simulation should be ‘more fully integrated into the health
service’. A subsequent report, A Framework for Technology Enhanced Learning (Department of Health,
2011), set out a vision to enable commissioners across health and social care to integrate technology
into education, training and continuing professional development. In 2013, Health Education England
(HEE) launched the Technology Enhanced Learning (TEL) Programme3 with the vision that healthcare
in the UK should be underpinned by world-class education and training that is enhanced through
innovation and the use of existing, evidence-based and emergent technologies and techniques (including
simulation). These aims concur with those outlined in the Scottish White Paper Partnership for Care (NHS
Education for Scotland (NES), 2007)4 , namely that, ‘Staff need to have the tools to do their job. So we
are investing heavily, not only in NHS staff themselves, but also in modernising the infrastructure of NHS
Scotland, and, above all, in the information systems and communications technology necessary to deliver
redesigned healthcare.’

Since then, a variety of initiatives have progressed at a national and local level. To take account of these
developments the Association for Simulated Practice in Healthcare (ASPiH) conducted a survey, The
National Simulation Development Project: Summary Report (ASPiH, 2014), to scope current provision for
SBE, including the assessment of capacity for teaching, within the UK. Importantly, the report concluded that:

• There is a growing body of evidence to support the use of SBE in healthcare

• SBE is used widely for training in core technical skills for craft specialties and other disciplines
• The presence of SBE in core curricula for most medical specialties and for nursing is increasing
• The UK has the highest number of advanced simulation centres in Europe
• The NHS is regarded as a global leader in the field of SBE.

Despite these promising factors, the report noted that funding, staff training and the availability
of educational faculty were the key constraints to the wider adoption of SBE. In particular, that the
management, sharing and co-ordination of resources between centres delivering SBE was poor in many
areas. This finding is especially significant given that over 80% of advanced simulation centres reported
having spare capacity.

3 Available at: https://www.hee.nhs.uk/our-work/research-learning-innovation/technology-enhanced-learning

4 Available at: http://www.gov.scot/Publications/2003/02/16476/18737
7
The role of SBE in physician training

Core Medical Training (CMT) provides the fundamental building blocks for all the physician specialties,
particularly in preparing doctors for the demanding role of Medical Registrar. It is therefore vital that
CMT doctors receive the necessary training to be fully equipped to competently and confidently perform
this role, and SBE is one route to achieving this outcome. It is likely that the principles of SBE established
during CMT will be relevant to higher medical specialty training.

A number of descriptions of SBE and its potential application exist in the literature. Key examples include:

SBE should be considered ‘a technique not a technology, to replace or amplify real experiences with
guided experiences’ (Gaba, 2004). Uniquely, it offers the chance for a learner to practise an activity in a
safe environment without compromising patient safety (Weller et al., 2012).

SBE can be used to deliver a wide range of curriculum requirements through case studies and role plays,
‘part task trainers’ (simulation of procedures) or ‘full mission simulators’ where a learner works through a
simulated scenario, often using a high-tech manikin (Beaubien, 2004).

Simulation lends itself particularly well to procedures or emergency situations which occur infrequently,
but are potentially dangerous or even life-threatening (Aggarwal et al., 2010).

The concept of ‘deliberate practice’, where repetitive practice of a skill in a focussed domain is associated
with improved performance (Ericsson, 2004), is thought to be enhanced by SBE. Rather than being
used to simply introduce a learner to a new skill, simulation when repeated multiple times can lead to
eventual mastery of the skill (Motola et al., 2013; Issenberg et al., 2005).

8
Methodology
To inform this report, the principal authors undertook a review of the literature relating to the use of
simulation-based education (SBE) in teaching the current Core Medical Training (CMT) curriculum. In
order to simultaneously assess current use and potential capacity of simulation in CMT across the UK, a
survey of CMT Training Programme Directors (TPDs) was conducted with the University of Dundee. The
findings are detailed below.

1) Literature review

A review was conducted to identify all aspects of the CMT curriculum (2009 with amendments by the
Joint Royal Colleges of Physicians Training Board (JRCPTB) in 2013) where evidence for SBE exists in the
literature.

Searches were conducted using the MEDLINE database and limited to English language only and
articles published from 1996 to 2015. In order to identify appropriate search terms, the two-page
‘Syllabus contents’ section of the curriculum was used. All terms listed within ‘common competencies’,
‘emergency presentations’, ‘top presentations’, ‘other important presentations’, ‘investigation
competencies’ and ‘procedural competencies’ were searched. These search terms were combined with
the term ‘simul*’.

Articles relating to specialties other than General Internal Medicine (GIM) or undergraduate medical
students were also included, providing it was clear that there was significant teaching overlap with
CMT curriculum requirements in the competency or presentation being assessed. Educational outcomes
included knowledge, time skills and behaviours, process skills and behaviours, product skills and
behaviours, as well as patient effect.

Two assessors with experience in SBE considered the abstracts for all of the returned citations for
suitability of inclusion in the study. The level of evidence demonstrated in individual papers was graded
T1 to T3.5

• T1 level evidence is where an effect is demonstrated in the simulation centre

• T2 is where an effect on downstream patient care behaviours and practices is demonstrated
• T3 is where an effect attributable to simulation on patient care or public health is demonstrated.

5 Rather than using the traditional hierarchy of scientific evidence, the relative strength of studies in SBE research is
conventionally graded in terms of their impact as a translational science. For this reason, even a rigorously conducted
randomised control trial may only be graded as T1 evidence if the outcome measurement demonstrates improvements
in care in a simulation centre rather than at the bedside.
9
Studies were classified as being either ‘positive’, ‘neutral’ or ‘negative’. A positive study was considered
to be one where the main outcome showed a statistically-significant effect in favour of simulation.
A neutral study was considered to be one where the main outcome did not show any statistically-
significant effect in favour of either simulation or the teaching modalities to which it was being
compared. A negative study was considered to be one where the main outcome showed a statistically-
significant effect in favour of alternative teaching modalities to which simulation was being compared.

Where articles were deemed appropriate for inclusion, relevant data were extracted and entered into the
following table:

Skill Study title & author Evidence level Outcome Specialty

2) Survey of CMT Training Programme Directors (TPDs)

A web-based survey evaluating the current use of SBE in CMT, as well as canvassing views on the
feasibility of making such training mandatory, was sent to all UK CMT TPDs in February 2015. The survey
was live for two weeks, during which time one email reminder was sent mid-term. The full questionnaire
is provided as Appendix 3.

A further survey of UK postgraduate Deans was conducted in summer 2016.

10
Results
1) Literature review

Evidence relating to elements of the Core Medical Training (CMT) curriculum

Out of the 20,564 articles identified by the original search terms, evidence of the use of simulation-based
education (SBE) in teaching content relevant to General Internal Medicine (GIM) was identified in a total
of 95 individual studies.

Positive evidence supporting training using SBE was found in a total of 90 individual studies applicable
to 7/25 of skills listed in the ‘common competencies’ domain of the CMT curriculum, 4/4 in ‘emergency
presentations’, 4/22 in ‘top presentations’, 2/26 in ‘investigations’ and 8/9 in ‘procedures’. Neutral
evidence was found in four individual studies relevant to 1/4 in the ‘emergency presentations’ domain of
the CMT curriculum, 2/22 in ‘top presentations’ and 1/9 in ‘procedures’. Evidence of negative effects of
teaching using SBE was found in a single T3 study relevant to the ‘communication within a consultation’
skill in the ‘common competencies’ domain of the CMT curriculum (Curtis et al., 2013).

The vast majority of papers regarded as showing a positive outcome only did so at T1 level; namely, there
was no direct effect on trainee behaviour in real life practice or on patient-related outcomes. However,
many were not designed to evaluate T2 or T3 outcomes and, furthermore, there is little evidence existing
at T3 level outside of SBE in the wider medical education literature.

Table 1 summarises the areas of the CMT curriculum where evidence was identified to support the use of
SBE in teaching and the associated grading of evidence. More details of the key references are provided
in Appendix 4. A full list of the studies identified by the review is available from the Joint Royal Colleges
of Physicians Training Board (JRCPTB) website (www.jrcptb.org.uk).

Key to Table 1:

• T1 evidence — denotes an effect in a simulation centre

• T2 evidence — denotes an effect on downstream patient care behaviours and practices
• T3 evidence — denotes an effect on patient care or public health.

11
TABLE 1
Competency Outcome Key reference
level [no.
of papers]
Common Clinical examination T2 [1] (Fraser et al., 2011)
competencies
Decision making and clinical reasoning T1 [1] (Howard et al., 1992)
Relationships with patients and T2 [1] (Fallowfield et al., 2002)
communication within a consultation
Breaking bad news T2 [1] (Fallowfield et al., 2002)
T1 [12]
Communication with colleagues and T1 [8] (Blum et al., 2003)
co-operation
Teamworking and patient safety T1 [3] (Blum et al., 2003)
Complaints and medical error T1 [1] (Sukalich et al., 2014)

Emergency Cardiorespiratory arrest T3 [2] (Mundell et al., 2013)

presentations T2 [1]
T1 [5]
Anaphylaxis T1 [5] (McCoy et al., 2011)
Shocked patient T1 [4] (Lighthall et al., 2003)
Unconscious patient T1 [1] (Owen et al., 2006)
Top presentations Abdominal pain T1 [2] (Steadman et al., 2006)
Breathlessness T1 [1] (Steadman et al., 2006)
Chest pain T2 [1] (Fraser et al., 2011)
T1 [1]
Management of patients requiring T1 [3] (Harting et al., 2008)
palliative and end-of-life care
Investigations Blood biochemistry T1 [1] (Botezatu et al., 2010)
Blood haematology T1 [1] (Botezatu et al., 2010)
Procedures Intercostal drain insertion (all T1 [6] (Hutton et al., 2008)
techniques including Seldinger)
Lumbar puncture T2 [2] (White et al., 2012)
T1 [6]
DC cardioversion T1 [3] (Healey et al., 2010)
Central venous catheterisation (CVC) T3 [5] (Barsuk et al., 2009)
T2 [2]
T1 [7]
Pleural aspiration (thoracentesis) T3 [1] (Duncan et al., 2009)
T2 [1]
T1 [3]
Abdominal paracentesis (including T3 [1] (Barsuk et al., 2014)
ascitic tap) T1 [2]
Knee aspiration T1 [5] (Jolly et al., 2007)
Nasogastric tube insertion T1 [1] (Bosse et al., 2015)

12
Evidence relating to non-technical skills and the human factors approach

The literature review found four studies with T2 level and 25 studies with T1 level evidence for teaching
‘common competencies’, such as communication and teamwork, effectively with SBE.

Simulation, by role play or with standardised or simulated patients6 , is a commonly used method of
teaching communication skills due to its simplicity, relatively low cost and effectiveness.

Standardised patients can be used in scenarios such as breaking bad news, disclosing medical errors,
and discussing end-of-life issues. One study looked at the use of simulated consultations to develop
communications skills for neurology trainees, which involved 12 specialist registrars in neurology (Smith
et al., 2002). The study concluded that trainees particularly valued being able to review recordings of
their consultations with simulated patients, which enabled them to reflect upon and improve their
history-taking skills and imparting of information to patients.

SBE also offers an opportunity to enhance trainees’ understanding and awareness of the importance
of ‘human factors’ in healthcare. Human factors are ‘attributes that diminish the ability of humans to
perform the necessary steps to succeed consistently in the complexity of real-world settings’ (Weinger
& Englund, 1990) and, over the past 20 years, a deeper understanding has been gained of the role they
play in clinical error. Human factors teaching using SBE may include teaching on recognition of, and
strategies to cope with, workplace issues, such as task prioritisation skills in times of high workload,
dealing effectively with distraction and avoiding ‘fixation error’.7

A systematic review meta-analysis (Cook et al., 2011) showed that SBE at postgraduate level consistently
achieved improved educational outcomes across a wide range of clinical topics and types of SBE, when
using no educational intervention as a control. Thus SBE can be effectively used to teach not only
knowledge and technical skills, but also non-technical and behavioural skills, enabling doctors to provide
safe and effective healthcare for patients.

2) Survey of CMT Training Programme Directors (TPDs)

A response rate of 67% was obtained (16/24 CMT TPDs). The survey revealed that, at present, use of
simulation to train in procedural skills, emergency presentations and non-technical skills is already high
in CMT. Furthermore, the majority of CMT TPDs consider it feasible for this training to be mandatory.
A summary of results is presented in Table 2.

6A ‘standardised patient’ is someone who has been trained to portray a patient in a medical situation in a consistent,
standardised manner.
7 ‘Fixation error’ describes when a practitioner becomes fixated on completing a discrete task, rather than stepping back and
considering the more pressing global picture (Weinger & Gaba, 2014).
13
TABLE 2
Survey questions (paraphrased for brevity) % positive response
Do you use simulation to train procedures in CMT? 100
Use of simulation to train CORE/ESSENTIAL procedures:
Advanced CPR 75
Ascitic tap 69
Lumbar puncture 88
Nasogastric tube placement 56
Pleural aspiration/intercostal drain insertion 100
Use of simulation to train DESIRABLE procedures:
Central venous cannulation 88
DC cardioversion 63
Intercostal drain insertion (Seldinger) 81
Abdominal paracentesis 63
Knee aspiration 19
Would it be feasible to make procedures training mandatory in CMT? 88
Use of simulation to train emergency presentations other than 69
cardiorespiratory arrest e.g. shock, loss of consciousness, anaphylaxis
Use of simulation to teach non-technical skills 75
Use of simulation to teach the following non-technical skills:
Situational awareness 63
Team communications 69
Leadership 63
Decision making 56
Prioritisation 50
Challenging communication e.g. breaking bad news 56
Task management 44
Other human factors 44
Would it be feasible to make simulation teaching of non-technical 75
skills mandatory in CMT?

14
The findings from the UK postgraduate Deans survey are presented in Table 3.

TABLE 3
Deanery/HEE local office I am assured that my Core I have considered whether
Medical Training programme there are funding implications
has the capacity to around mandating the use
accommodate the delivery of simulation in Core Medical
and assessment of the Training curricula in terms
recommended changes of existing capability and
capacity

HENE Yes Yes

HENW Yes Yes
HEYH Yes Yes
HEWM Yes Yes
HEEM Yes Yes
HEEoE Yes Yes
HESW - -
HEWessex Yes Yes
HETV Yes Yes
HENCEL Yes Yes
HENWL Yes Yes
HESL Yes Yes
HEKSS - -
Defence Deanery Yes Yes
NES Yes Yes
Welsh Deanery Yes Yes
NI Deanery Yes Yes

15
Discussion
There is a broad evidence base supporting the use of simulation-based education (SBE) to enhance
teaching of the medical curricula generally. This report investigated how simulation might specifically
be applied to enhance teaching for Core Medical Training (CMT) trainees. Further consideration of the
findings of the literature review and their practical implications are discussed below.

Procedural competency training

There is some T3 level evidence that SBE enhances the effectiveness of teaching procedural aspects of
the CMT curriculum (central venous catheterisation, thoracentesis, abdominal paracentesis) and also
emergency scenarios (cardiorespiratory arrest). There is a broad range of (mainly T1 level) evidence that
suggests SBE can safely enhance the teaching of all other procedural competencies for CMT and also
emergency presentations and top presentations.

Occasionally, other curricula may provide more details on particular procedures, for example, the
Advanced Life Support (ALS) curriculum (Resuscitation Council, 2015) covers cardiopulmonary
resuscitation and transcutaneous cardiac pacing, and, where these exist, they should also be referred to
when devising training programmes to prevent duplication.

In some cases, CMT trainees may have already received training in certain procedures listed in the CMT
curriculum, for example, nasogastric tube insertion, at Foundation Level. Unfortunately, this does not
necessarily mean they are fully competent (Lee & Mason, 2013), and trainers need to consider where
best to invest the training resources at their disposal for CMT whilst taking national guidance or local
feedback on patient safety matters into account.

Non-technical and human factors skills

Aside from its clear role in enhancing the effectiveness of teaching procedural aspects of the CMT
curriculum, SBE also offers an opportunity to deepen understanding and awareness of the importance of
non-technical skills, such as communication and ‘human factors’ in healthcare delivery.

16
The development of good communication skills is a key requirement for becoming an effective physician.
Studies have shown that improved patient-centred communication can improve patient satisfaction and
biomedical outcomes (Stewart, 1995).

Human factors have been described as ‘attributes that diminish the ability of humans to perform the
necessary steps to succeed consistently in the complexity of real-world settings’ (Weinger & Englund,
1990) and, over the past 20 years, a greater understanding has been achieved of the role they play in
clinical errors.

Teaching human factors using SBE has the potential to help individuals recognise and devise coping
strategies for dealing with challenging non-technical issues, such as task prioritisation in times of
high workload, managing distraction and avoiding ‘fixation error’. It can also improve patient safety
by ensuring a teamworking approach. For example, operating theatre staff who underwent human
factors training demonstrated significant improvements in non-technical skills and behaviours as well
as technical skills, compared to before they received training (McCulloch et al., 2009). Emergency
Department staff who underwent human factors training demonstrated significantly improved team
behaviours, in addition to a significant reduction in the number of clinical errors they made, compared
with staff who had not undergone this training (Morey et al., 2002).

A multi-disciplinary simulation-based teamwork and communication training event in a US Paediatric

Emergency Department resulted in significant improvements in staff knowledge and a reduction in
patient safety events (Patterson et al., 2013). Following the intervention, the authors noted that the
department managed 1,000 days without a single patient safety event, compared with a pre-intervention
baseline rate of 2–3 events per year.

Another example of a successful teamworking application involved a multi-centre US randomised

controlled trial, where clinical stroke rehabilitation staff from six professional disciplines were assigned
to either a six-month ‘team training intervention’ (involving 2.5 days of training, written exercises and
a videoconference consultation) or to ‘no training’. Observed functional motor outcomes in stroke
rehabilitation patients treated by the intervention group were significantly improved, compared to those
treated by the non-intervention group, for the following 12 months (Strasser et al., 2008).

Practical considerations for delivering SBE

The literature also highlighted some important factors associated with the effective delivery of SBE:

• Retention of skills and knowledge degrade with time, particularly with seldom-performed procedures
or activities (McGaghie et al., 2010). High-fidelity SBE can be used annually to retain procedural skills
(Boet et al., 2011)

• Conducting scenario-based SBE in situ can ensure a more realistic exercise than in a simulation centre,
as well as allowing live drills to be conducted by real teams. Additionally, it can help with the detection
and resolution of ‘latent errors’8 (Miller et al., 2008)

• Using SBE to perform paracentesis procedures at the bedside resulted in cost savings compared to
performing these procedures in a radiology department (Barsuk et al., 2014).

8 ‘Latent errors’ are events that are identified during in situ simulation exercises, which, if occurred in a real-life setting, may
cause a degree of harm to the patient.
17
Recommendations
The findings of the literature review highlight the potential enhancements to patient safety and the
quality of care that may be achieved through increasing use of simulation-based education (SBE) within
postgraduate medical education. Whilst the survey results highlight there is already widespread use of
SBE to teach the Core Medical Training (CMT) curriculum across the UK, the outcomes illustrate where
those efforts might best be directed. Indeed, the extent to which SBE is currently used to teach CMT is
such that, for quality management purposes, its universal implementation in CMT should now become
a priority. This proposition is supported by the evidence that SBE teaching of some CMT procedures and
emergency presentations improves patient outcomes. The main findings are:

• There is good evidence (T3) that certain CMT practical procedures (central venous catheterisation,
thoracentesis, abdominal paracentesis) and emergency presentations (cardiorespiratory arrest)
can improve patient outcomes if taught by SBE. There is no obvious reason why additional CMT
procedures should not also be taught using SBE, indeed, the evidence points to it being desirable to
do so

• There is reasonable evidence (T2) that non-technical and human factors skills required by CMT can be
taught effectively using SBE

• The teaching of CMT essential and desirable procedures, and also non-technical skills using SBE, is
already widespread within the UK and that CMT Training Programme Directors (TPDs) support this
training.

Specific recommendations to mandate the use of SBE in CMT

Based on these findings, the Joint Royal Colleges of Physicians Training Board (JRCPTB) intends to submit
a revised CMT curriculum to the General Medical Council (GMC) to consider mandating the following:

That all essential and desirable practical procedures listed in the CMT curriculum should
be taught by simulation as early as possible in Year One, with further simulation teaching,
involving human factors and scenarios training, carried out in either Year One or Year Two.
The latter should also include refresher training for procedural skills, where necessary.

The evidence reviewed suggests that UK Deanery and Health Education England (HEE) Local Office
Schools of Medicine should deliver the following:

a) Procedural competency training, using simulation aimed at achieving technical competence for
all essential and desirable procedures in the CMT curriculum, as early as possible during Year One (see
Appendix 2 for more details).

b) Scenario-based immersive simulation training, addressing the management of shock, the

unconscious patient, anaphylaxis and cardiorespiratory arrest, in Year Two.

In addition, further scenarios which explore the differential diagnosis and management of abdominal
pain, chest pain and breathlessness should be included in the simulation teaching. Other aspects of the
curriculum that should be covered include management of patients requiring palliative and end-of-life
care, communication within a consultation and breaking bad news. Teaching of human factors can also
be incorporated into these scenarios.

18
Other recommendations

1. The Association for Simulated Practice in Healthcare (ASPiH) report, The National Simulation
Development Project: Summary Report (ASPiH, 2014), highlighted funding, staff training and the
availability of education faculty as key constraints to the wider adoption of SBE. Given the challenging
funding environment, it is important that improvements are sought through multiprofessional
collaboration where possible, including sharing equipment and costs with other departments, such
as Emergency Medicine, Paediatrics and Anaesthetics, who are already active and regular users of
simulation equipment and facilities. Indeed, the ASPiH report (2014) revealed that over 80% of advanced
simulation centres had spare capacity, which should prompt discussion, perhaps at a regional level, as to
how to make best use of the facilities available. In addition, existing programmes should be considered
as to how they might assist the wider provision of SBE training. Such programmes may incorporate
scenario-based simulation, procedural skills training and communication skills, and may therefore be
considered to deliver these curriculum requirements.

2. Patient safety can be improved by conducting scenario-based SBE in situ. This provides a more realistic
environment than a simulation centre, allows live drills to be conducted with real teams and, additionally,
can help in the detection and resolution of ‘latent errors’ (Miller et al., 2008).

3. Where alternative curricula already teach aspects of the CMT curriculum through simulation (for
example, ALS and Foundation Level), they should be taken into account when training programmes are
devised, to prevent duplication.

Update: ASPiH has been engaged by HEE to further develop its simulation standards in 2016/17
with the objective of having national standards, backed by a full consultation process across all
stakeholders. The draft standards were presented at the ASPiH 2016 Conference in November 2016.

19
Simulation-based education (SBE)
can improve the quality and impact
of training provided to doctors
now and in the future

20
Conclusion
Simulation-based education (SBE) can improve the quality and impact of training provided to doctors
now and in the future. For teaching to deliver maximum benefit, it should be closely aligned to the
relevant educational curriculum, informed by the evidence base and adhere to the highest quality
standards.

This document provides more evidence and detail on how this vision can now be achieved for Core
Medical Training (CMT). The development of accompanying standards9 for the delivery of SBE for
CMT heralds the next step in creating a clear framework for SBE to be provided systematically within
all postgraduate medical curricula. It is hoped that further strides will quickly be made to advance this
aspiration, thus providing regular opportunities for SBE throughout doctors’ careers. The evidence
indicates that this is an effective route for ensuring skills and knowledge are kept up to date, whilst
delivering tangible improvements in patient outcomes.

9 For more details see: http://www.aspih.org.uk/

21
22
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Appendix 1 — Membership of the joint JRCPTB/HEE Expert
Group on Simulation in Core Medical Training
Group membership is primarily from the medical and educational fields, representing all levels of the
medical education system from trainees to Deanery/Health Education England (HEE) local office level
across the UK. Names and titles were accurate as per the last meeting of the Group.

Members of the Small Working Group on Simulation in Core Medical Training:

Professor David Black (Chair), Medical Director, Joint Royal Colleges of Physicians Training Board (JRCPTB)

Dr Miriam Armstrong, Senior Policy Adviser, JRCPTB

Dr Ian Barrison, Associate Dean — Postgraduate Medicine, University of Hertfordshire

Catherine Boyd, Lay Member, JRCPTB and Royal College of Physicians of Edinburgh (RCPE); Lay Adviser,
Health Education North West

Dr Nicki Colledge, Director of Education, RCPE

Dr Graham Fent, Educational Leadership in Simulation Fellow, School of Medicine, Health Education
Yorkshire and the Humber

Professor Jean Ker, NHS Education for Scotland (NES) National Clinical Lead for Skills and Simulation;
Associate Dean of Innovation and Medical Education, Ninewells Hospital and Medical School, Dundee

Dr Anoop Prakash, Educational Leadership in Simulation Fellow, School of Medicine, Health Education
Yorkshire and the Humber

Dr Makani Purva, Director of Medical Education, Hull and East Yorkshire Hospitals NHS Trust

Emma Scales, Programme Lead for TEL, HEE

Winnie Wade, Director of Education, Royal College of Physicians of London (RCPL)

Additional members of the Expert Group on Simulation in Core Medical Training:

Professor Bill Burr, Medical Director, JRCPTB (Chair until 1 August 2014)

Fiona Carmody, TEL Programme Administrator, HEE

Dr Indranil Chakravorty, Consultant in Acute and Respiratory Medicine, St George’s Hospital, London

Dr Andrew Douds, CMT Simulation Lead, Health Education East of England

Dr Pramod Luthra, Associate Postgraduate Dean, Health Education North West

Dr Shairana Naleem, Consultant Acute Physician and CMT Simulation Lead, King’s College Hospital and
Health Education South East London

Dr Hina Pattani, CMT Lead, Health Education South East London

26
Dr Mohammed Peerally, Academic Clinical Fellow, University Hospitals of Leicester NHS Trust

Dr Paul Rylance, Director, NHS Teaching Academy, Royal Wolverhampton NHS Trust

Dr Nadia Short, Training Programme Director and Simulation Lead, Health Education South East

Dr Mukesh Thakur, General Internal Medicine Training Programme Director, Health Education Yorkshire
and the Humber

Dr Michael Trimble, Deputy Director, Ill Medical Patients’ Acute Care and Treatment (IMPACT)
Programme; Head of School of Medicine, Northern Ireland Medical and Dental Training Agency

Dr Emma Vaux, Chair, JRCPTB CMT Advisory Committee; Consultant Nephrologist and Programme
Director of Quality Improvement, Royal Berkshire NHS Foundation Trust

27
Appendix 2 — Procedural competencies for CMT (2009
10
curriculum — amendments approved 28 August 2013)
As a minimum, the specialty registrar (StR) must be able to outline the indications for these procedures,
recognise the importance of valid consent, aseptic technique, safe use of analgesia and local
anaesthetics, minimisation of patient discomfort and when to request help. It is good medical practice to
obtain training in procedural skills in a clinical skills lab before performing these procedures clinically.

The procedural competencies for the Core Medical Training (CMT) framework are divided into three
sections:

Essential CMT procedures (part A, clinical independence essential)

CMT StRs must be able to undertake the following procedures before completion of CMT:

• Advanced cardiopulmonary resuscitation (including external pacing)

• Ascitic tap
• Lumbar puncture
• Nasogastric tube placement and checking
• Pleural aspiration or intercostal drain insertion for pneumothorax.

Essential CMT procedures (part B, clinical independence desirable)*

CMT StRs must have some experience* of these procedures before completion of CMT:

• Central venous cannulation (by neck or femoral) with ultrasound (U/S) guidance where appropriate
• DC cardioversion
• Intercostal drain insertion using Seldinger technique with U/S guidance (excepting pneumothorax).

* Trainees considering progression into an acute medical specialty are expected to develop clinical
independence in these procedures, where possible. If not able to gain clinical independence, then one
or more of the following are acceptable: skills lab competent with certification, course competent with
certification, some clinical experience with Directly Observed Procedural Skills (DOPS) indicating, at a
minimum, ‘able to perform the procedure under direct supervision/assistance’.

10 Available
at: http://www.jrcptb.org.uk/sites/default/files/FINAL%202009%20CMT%20Curriculum%20
%28AMENDMENTS%20Aug%202013%29_0.pdf
28
Desirable CMT procedures

CMT StRs should try to gain at least some experience**, and independent competency if possible, in
the following procedures. However, it is recognised that it may be difficult to gain experience in these
procedures because of reduced opportunities due to changed clinical practice and patient safety issues.
The ability to undertake these procedures will be dependent on the training opportunities within a
particular programme.

• Abdominal paracentesis
• Knee aspiration.

**If not able to gain clinical independence, then one or more of the following are acceptable: skills lab
competent with certification, course competent with certification, some clinical experience with DOPS
indicating, at a minimum, ‘able to perform the procedure under direct supervision/assistance’.

Foundation procedural competencies

The CMT StR is expected to be competent, and maintain competency, in the following practical
procedures in the Foundation curriculum during CMT:

• Arterial blood gas sampling

• Cannula insertion, including large bore
• Electrocardiogram
• Peak flow measurement
• Urethral catheterisation
• Venepuncture

29
Appendix 3 — UK CMT Training Programme Director (TPD)
web-based survey

30
31
32
Appendix 4 — Details from key references identified from the
literature search

Skill Study title & author Evidence Outcome Specialty

level
Common competencies
Clinical Simulation training improves T2 Students able to Undergraduate
examination diagnostic performance on a diagnose murmurs
real patient with similar clinical in real-life chest pain
findings patients following SBE
(Fraser et al., 2011)
Decision making Anesthesia crisis resource T1 Improvement in Anaesthetics
and clinical management training: teaching knowledge regarding
reasoning anesthesiologists to handle management
critical incidents of emergency
(Howard et al., 1992) presentations
following SBE
Relationships Efficacy of a Cancer Research T2 Oncology doctors Oncology
with UK communication skills randomised to SBE
patients and training model for oncologists: course demonstrated
communication a randomised controlled trial better communication
within a skills across wide
consultation range of oncology
& issues in real patients
Breaking bad
news
Communication Crisis resource management T1 Self-reported Anaesthetics
with colleagues training for an anaesthesia improvements in
and co- faculty: a new approach to communication,
operation continuing education teamwork and crisis
& (Blum et al., 2003) resource management
Teamworking skills following SBE
and patient
safety
Complaints and Teaching medical error T1 Improvement in General
medical error disclosure to residents using disclosure of medical Internal
patient-centred simulation error following SBE Medicine (GIM)
training
(Sukalich et al., 2014)
Emergency presentations
Cardio- Simulation technology for T3 Improved patient Mixed
respiratory arrest resuscitation training: a outcomes from
systematic review and meta- resuscitation
analysis following SBE
(Mundell et al., 2013)

33
Anaphylaxis Prospective randomized T1 Improved treatment Undergraduate
crossover study of simulation of anaphylaxis
vs. didactics for teaching following SBE
medical students the
assessment and management
of critically ill patients
(McCoy et al., 2011)
Shocked patient Use of a fully simulated T1 Self-reported GIM
intensive care unit environment improvements in
for critical event management ability to manage
training for internal medicine patients with shock
residents following SBE
(Lighthall et al., 2003)
Unconscious Comparison of three T1 Improved treatment GIM
patient simulation-based training of unconscious
methods for management of patient with full
medical emergencies mission simulation
(Owen et al., 2006)
Top presentations
Abdominal pain Simulation-based training is T1 Improved critical Undergraduate
& superior to problem-based assessment and
Breathlessness learning for the acquisition management skills
of critical assessment and with SBE vs problem-
management skills based learning
(Steadman et al., 2006)
Chest pain Simulation training improves T2 Students able to Undergraduate
diagnostic performance on a diagnose murmurs
real patient with similar clinical in real-life chest pain
findings patients following SBE
(Fraser et al., 2011)
Management Computer-based simulation as T1 Improvements in GIM
of patients a teaching tool for residents management of pain
requiring treating patients with cancer- following use of
palliative and related pain crises computer simulation
end-of-life care (Harting et al., 2008) program
Investigations
Blood Virtual patient simulation: T1 Improved knowledge Undergraduate
biochemistry knowledge gain or knowledge retention with virtual
& loss? patient simulation
Blood (Botezatu et al., 2010)
haematology
Procedures
Intercostal Using simulation models to T1 Improvement in GIM
drain insertion teach junior doctors how to insertion of intercostal
(all techniques insert chest tubes: a brief and drain following SBE
including effective teaching module course
Seldinger) (Hutton et al., 2008)

34
Lumbar Transfer of simulated lumbar T2 Trainees performed Paediatrics
puncture (LP) puncture training to the clinical LP competently in real
setting patients following
(White et al., 2012) training using task
trainer
DC cardioversion A low-fidelity simulation T1 Improvement in GIM
(DCCV) curriculum addresses needs self-reported ability
identified by faculty and in performing DCCV
improves the comfort level following SBE course
of senior internal medicine
resident physicians with
inhospital resuscitation
(Healey et al., 2010)
Central venous Simulation-based mastery T3 Fewer catheter- GIM/Emergency
catheterisation learning reduces complications related bloodstream Medicine
(CVC) during central venous catheter infections in ICU
insertion in a medical intensive patients following SBE
care unit
(Barsuk et al., 2009)
Pleural Reducing iatrogenic risk in T3 SBE in ultrasound- GIM
aspiration thoracentesis: establishing best guided thoracentesis
(thoracentesis) practice via experiential training resulted in lower rates
in a zero-risk environment of pneumothorax
(Duncan et al., 2009)
Abdominal Cost savings of performing T3 Reduced cost and Mixed
paracentesis paracentesis procedures at the reduced need for
(including ascitic bedside after simulation-based platelet or fresh
tap) education frozen plasma
(Barsuk et al., 2014) (FFP) transfusion
when paracentesis
performed after SBE
vs standard methods
Knee aspiration Influence of an interactive joint T1 Self-reported GIM
model injection workshop on improvement in joint
physicians’ musculoskeletal aspiration following
procedural skills SBE course
(Jolly et al., 2007)
Nasogastric (NG) The benefit of repetitive skills T1 Improved Undergraduate
tube insertion training and frequency of performance in NG
expert feedback in the early tube placement with
acquisition of procedural skills deliberate practice/
(Bosse et al., 2015) SBE

35