Can simulation training improve foundation doctors’ assessment and management of acutely unwell surgical patients?

Starting a foundation surgical job is a daunting prospect for many newly qualified doctors. Being on call, especially at night, often requires all of the medical skills acquired during training, but many graduate doctors think that they are inadequately prepared for this task. Suboptimal initial ward management is known to delay admission to intensive care and increase morbidity and mortality,1 and junior doctors are often the first to attend to acutely unwell patients.

Junior doctors have said that they often fail to appreciate the clinical urgency of cases and are reluctant to start initial management for fear of causing harm.2 Furthermore, they are reluctant to call for help early on to avoid failing their own and seniors’ expectations, think that they lack the practical knowledge, and have difficulties in translating theoretical knowledge into practice.2

The competencies in the care of acutely ill patients that medical students should possess before graduation were specified in the Acute Care Undergraduate Teaching project in 2005.3 In addition, a key priority in the National Institute for Health and Care Excellence’s 2007 guidelines on treating acutely ill patients in hospital was that “education and training should be provided to ensure staff are competent in monitoring, measurement, interpretation and prompt response to the acutely ill patient.”4

The fact that junior doctors believe they are poorly prepared when assessing acutely unwell surgical patients may be related to the limited exposure medical students have to these patients.

At a national course on the recognition and management of acutely unwell surgical patients held by the University of Leicester Student Surgical and Anaesthetic Society, students were asked how many times they had shadowed the surgical on-call team. Of 66 students participating in the course, 45 (68%) completed the questionnaire. Only 17.4% of respondents had shadowed an on-call surgeon more than five times, despite 89% of respondents being fourth and fifth year students. As well as lack of exposure, students cited a lack of confidence when treating acutely unwell surgical patients.

What can be done to correct this? In addition to medical schools ensuring that students spend more time shadowing the on-call team, other training methods are needed to give students the necessary skills and confidence. Students must take some responsibility for their learning, embracing all learning opportunities and remembering that they will one day manage deteriorating patients. Shadowing the on-call team is an easy way to experience management of acutely unwell patients. Students can also attend one of the acute care and trauma courses available to medical students (table⇓). These courses will not only improve their knowledge, confidence, and skills but can also help students develop their CVs.

Simulations are also being increasingly adopted by medical educationalists to deal with the rift between classroom theory and clinical practice.5 The simulations aim to recreate genuine patient encounters in a controlled clinical environment without any risk to patients.

Evidence suggests that simulation based training gives students the skills and confidence to approach their foundation placement. Junior doctors have reported an increase in their self perceived ability to manage acutely unwell patients as a result of the simulation training they received at medical school.6 After receiving teaching using a simulated surgical patient, fourth year medical students did better in a senior surgery written OSCE (objective structured clinical examination) that included management of surgical patients.7 Simulation training on medical and surgical cases before graduation has also been shown to increase junior doctors’ preparedness for managing unwell patients on both surgical and acute care wards.6 Other studies have shown that simulation training increases students’ confidence in the assessment and management of critically ill patients,8 septic shock and severe sepsis,9 and medical emergencies,10 and in performing lifesaving procedures.11

The national course recently hosted by the University of Leicester Student Surgical and Anaesthetic Society consisted of focused lectures, case demonstrations, case discussions, and a basic surgical skills tutorial. It also included high fidelity structured interactive simulations. Feedback from the workshop was positive. Before the workshop, 47% of respondents were not confident in assessing a patient, but after the course this proportion improved to 100%. In addition, 100% of respondents felt more confident with the airway, breathing, circulation, disability, and exposure (ABCDE) approach to the acute patient, and 88% with starting initial management. The inclusion of simulated stations in courses required considerable planning and time, but they formed a useful adjunct to other forms clinical teaching. The stations enabled students to develop and consolidate essential practical and examination skills, and also helped students improve their confidence when presented with an acutely unwell surgical patient. All the students agreed that more simulation workshops should be included in the medical curriculum.

Simulation training is increasingly being used in medical teaching and is well received by students, as feedback from the Leicester course shows. It could therefore help to ensure foundation doctors feel better equipped for the daunting task of treating acutely unwell surgical patients.