Workshop Leaders: Sabrina Butteris , MD & Michael Pitt, MD Co-Presenters: Amer Al-Nimr, MD Jacquelyn Kuzminski, MD Anagha Loharikar, MD Molly Shane, MD Chuck Schubert, MD Nicole St. Clair, MD Sarah Webber, MD

Disclosure Slide

We have no financial relationships relevant to this workshop to disclose.

Questions/Wrap Up (25 min)

Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)

Break (10 min) Return in Small Groups

Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief

Break (10 min)

How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script

SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot

Welcome/Introductions (10 min)

Background • Supply is catching up to demand o Over half of pediatric residency programs offer GH electives

• Proper preparation is key

• Difficulty in handling the emotional obstacles encountered

abroad is frequently discussed in post-trip debriefing • Active preparatory curricula allowing residents to experience

and debrief potential emotional challenges encountered abroad are lacking

+

Could we use medical simulation to prepare global health residents for common emotional challenges encountered abroad, rather than just medical preparation?

Simulation Use for Global Away Rotations (SUGAR) • PRIMARY GOAL: Develop and

evaluate a standardized simulation curriculum to prepare residents to better deal with the common emotional challenges encountered on global health rotations

• SECONDARY GOALS: • Reinforce medical knowledge of

less familiar diseases and management

• Experience the challenges of working with limited resources

• Encourage problem-solving skills • Appreciate challenges of

providing care across cultures • Foster humility

Common emotions encountered on GH electives

• Frustration at slower pace, less urgency, lack of resources

• Difficulty understanding apparent differences in dealing with death and dying

• Battling a sense of superiority when it comes to medical management

• Fear or uncertainty with how to manage new diseases

Frustration

“I know what I would do back home to manage this disease, but I don’t have the ability to

do it here.”

Ex: DKA without an insulin drip

Adaptability

“I was able to overcome obstacles encountered in a

resource-limited environment and ultimately help this

patient.”

Floundering

“I don’t know what to do with the disease or where to find information that could help

me.”

Ex: Lymphocytic Interstitial Pneumonitis

Awareness of Resources

“I was able to utilize available resources to learn how to

manage a disease I had little experience with and ultimately

helped the patient.”

Turning an F into an A

Futility

“Why does everyone seem so complacent with death here? Am I the only one who cares?

What will happen to this patient if we ‘save’ her.”

Ex: Prolonged resuscitation of a neonate without access to a

ventilator

Acknowledgement

“Sometimes death is unavoidable. A patient dying is difficult for everyone; how this is expressed may be different than what I am accustomed to

but this doesn’t mean my hosts are not affected by it.”

Turning an F into an A

Failure

“I thought I knew how to make this patient better, but I am

making them worse. What is different about this patient in

this environment?”

Ex: Management of shock in severe acute malnutrition

Adjustment/ Humility

“I learned that having false assumptions that patients will always be physiologically the same as those I am used to,

can at times be harmful.”

2 Page Case Outline 1 Page Debriefing Script

&

SUGAR Study: Phase 1 • Seven institutions participated (IRB obtained at all)

• Program size ranged from 34-108 pediatric residents • 12-51% residents participating in GH • 5/7 programs with formal GH track

• Evaluation (anonymous and optional) • Residents

• How useful in preparation for GH elective • Emotions encounter during the case (if any) • Planned changes as a result of simulation (if any)

• Facilitators • How useful? • Emotions elicited (if any)

Results

95 residents invited across

seven sites

51 residents came to

session(s) (54%)

160 resident evaluations completed

75% from participants

25% from observers

16 facilitators across seven

sites

52 facilitator evaluations completed

1 Year | Seven Institutions

Resident and Facilitator Perception of the Usefulness of the Simulation Session

Category n (evaluations) Mean(SD)

Overall Resident 160 4.5 (0.8) Facilitator 52 4.9 (0.4)

Resident role Participant 128 4.5 (0.8) Observer 32 4.3 (1)

Resident level of training

PGY1 59 4.4 (0.7) PGY2 49 4.4 (1.1) PGY3 43 4.6 (0.5)

PGY4+ 9 5 (0)

Resident specialty

Pediatrics 134 4.5 (0.9) Medicine-Pediatrics 10 4.4 (0.8)

Family Medicine 12 4.7 (0.5) Fellow 4 5 (0)

Resident response by site

Site 1 25 4.8 (0.4) Site 2 6 4.8 (0.4) Site 3 2 5 (0) Site 4 11 4.8 (0.6) Site 5 37 3.8 (1.1) Site 6 20 4.8 (0.4) Site 7 59 4.6 (0.7)

Facilitator response by site

Site 1 7 4.7 (0.5) Site 2 6 4.7 (0.5) Site 3 3 4.7 (0.6) Site 4 11 4.9 (0.3) Site 5 4 4.8 (0.5) Site 6 10 5 (0) Site 7 11 4.9 (0.3)

Representative Quotes

“Frustration with lack of resources and the amount of time it took to do

simple tests.”

“Sadness that the child would return to a life of poverty and possibly dozens of recurrences.”

“Feeling helpless. Not knowing how to respond emotionally.” “Confusion at recognizing a

problem but being unsure of its treatment without labs, etc.”

ACTIVATED

REFLECTIVE

POSITIVE

NEGATIVE

Frustration (74/156; 47%) Anxiety/Worry (20; 13%) Uncomfortable (11; 7%) Fear (8; 5%) Stress/Overwhelmed (6; 4%)

Excited (3; 2%)

Incompetent/Ill-Prepared (9; 6%) Sadness (22; 14%) Helpless (20; 13%) Futility (7; 5%) Confusion (15; 10%) Guilt (2; 1%)

Satisfied (13; 8%) Confident (5; 3%) Curious (2; 1%)

No Emotion (3; 2%)

Conclusions • The novel SUGAR curriculum was able to be incorporated in

varied programs with reproducible success and minimal training

• Residents and facilitators overwhelmingly rated the

curriculum as useful • SUGAR was able to elicit emotions with over 98% of

residents’ comments indicated they had an emotional response and this was the most common theme of debriefing

• Residents indicated planned change to their preparation as

the result of this curriculum

Resident Response - Are there any changes to your global health rotation pre-trip preparation that you anticipate making as a result of this simulation session?

(n=137 written comments)

Change in Pre-Trip Preparation

Number of Comments with Theme

(%)

Representative Quote

Expand/review medical knowledge 76 (55) “Familiarize myself with common illnesses and

complications in limited resource settings.” Obtain and take specific resources with me 26 (19) “Bring WHO Hospital Care for Children* handbook

along with me.”

Learn about local resources 22 (16) “Taking more time to try and understand available resources and treatment limitations before scenarios arise.”

Cultural/language preparation 12 (9) “Knowing to talk with locals about end of life

culturally.” Emotional and mental preparation 9 (7) “Prepare to deal with difficult conversations with

parents.”

Learning about roles and expectations 7 (5) “Think about expectations and role.”

Practice/gain clinical skills 6 (4) "Practice Neonatal Resuscitation Program (NRP).”

No changes 6 (4) “Not pre-trip [changes], but it makes me more cognizant of asking about resources once arriving.”

*Pocket Book of Hospital care for children. WHO Press. 2013.

Limitations • Variations in numbers of cases completed at each

institutions make comparative statistics impossible • Did not assess whether residents’ anticipated

changes in preparation translate to actual changes in preparation before their trip (YET)

Next Steps • Publish and disseminate curriculum • New cases • Feedback on return from GH rotation

Acknowledgements

Cindy Howard, MD Chandy John, MD, MS Ann Campagna, MD Tina Slusher, MD

Sabrina Butteris, MD Laura Houser, MD Scott Hagen, MD

Walter Eppich, MD, Med Molly Shane, MD Anagha Loharikar, MD

Nicole St. Clair, MD Jacquelyn Kuzminksi, MD

Phillip Fischer, MD Jane Rosenman, MD

Amer Al-Nimr, MD

Chuck Schubert, MD Stephen Warrick, MD

Questions/Wrap Up (25 min)

Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)

Break (10 min) Return in Small Groups

Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief

Break (10 min)

How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script

SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot

Welcome/Introductions (10 min)

INSERT BINDER SCREENSHOTS ON NEXT SLIDES TABLE OF CONTENTS

INCOMPLETE

INSERT BINDER SCREENSHOTS ON NEXT SLIDES CASE EXAMPLE

INCOMPLETE

INSERT BINDER SCREENSHOTS ON NEXT SLIDES DEBRIEFING SCRIPT

INCOMPLETE

Questions/Wrap Up (25 min)

Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)

Break (10 min) Return in Small Groups

Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief

Break (10 min)

How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script

SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot

Welcome/Introductions (10 min)

Questions/Wrap Up (25 min)

Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)

Break (10 min) Return in Small Groups

Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief

Break (10 min)

How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script

SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot

Welcome/Introductions (10 min)

Some Tips for Observing • Follow along in the case (Case 1A)

• Pay particular attention to the introduction of obstacles and the use of silence

• Ask yourself what you would do in the resident’s position as well as in the facilitator’s role.

• Follow along with the debriefing script

DEBRIEFING

Questions/Wrap Up (25 min)

Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)

Break (10 min) Return in Small Groups

Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief

Break (10 min)

How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script

SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot

Welcome/Introductions (10 min)

Questions/Wrap Up (25 min)

Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)

Break (10 min) Return in Small Groups

Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief

Break (10 min)

How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script

SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot

Welcome/Introductions (10 min)

1. Break your small group into two groups (A&B)

2. Take 10 minutes to familiarize yourself with your case 1. Group A: Case 3A 2. Group B: Case 2B

3. Group A: Facilitate Case 3A for Group B

• 10 min case/10 min debrief

4. Group B: Facilitate Case 2B for Group A • 10 min case/10 min debrief

5. Group Feedback

Your Turn

Questions/Wrap Up (25 min)

Your Turn: Small Group Practice (60 min) Case Review (10 min) A Facilitates B (20 min) B Facilitates A (20 min) Group Feedback (10 min)

Break (10 min) Return in Small Groups

Demo: What does it Look Like? (40 min) Observe a Case Observe Debriefing Large Group Debrief

Break (10 min)

How to Do it: Binder Orientation (25 min) Case Walk-Through Debriefing Script

SUGAR Overview (15 min) What it is? Results of Multi-Institution Pilot

Welcome/Introductions (10 min)

https://www.appd.org/amsurvey/