Building expertise through simulations

As a teaching institution, Mayo Clinic is committed to training young physicians to provide the highest standards of patient care. All three Mayo campuses have simulation centers where neurologists and neurosurgeons gain experience that builds clinical expertise and communication skills. Utilizing actors and realistic mannequins, the scenarios depict neurological assessments and emergencies, and even family disputes, at the patient bedside. Evaluations by staff physicians immediately after the scenario provide feedback for young physicians.

"Simulations provide an exact clinical scenario in a controlled environment. Residents can gain experience, confidence and competence so that they know what to do in an acute neurological situation," says Dan J. Capampangan, M.D., a neurologist at Mayo Clinic in Phoenix, Arizona.

Realistic scenarios

The scenarios, which are written by Mayo neurologists, cover conditions such as:

  • Acute ischemic stroke
  • Status epilepticus
  • Acute respiratory distress in the context of myasthenia gravis
  • Raised intracranial pressure

Simulations are carried out in rooms modeled on emergency department or patient hospital rooms, complete with bedside monitors. Actors or programmable mannequins portray patients; Mayo staff physicians, nurses and respiratory therapists play themselves.

"The residents or trainees are expected to demonstrate their approach to the patient, in terms of the historical information that would be important as well as the examination findings," says Kevin M. Barrett, M.D., a neurologist at Mayo Clinic in Jacksonville, Florida. "We also incorporate radiologic scans to make sure the trainees can recognize acute problems and respond to them appropriately."

Staff physicians can watch the scenario from behind a one-way mirror. A mannequin patient, voiced by an actor behind the mirror, is programmed to show changing vital signs and behavior.

"The mannequin might be answering questions from the trainee doctor and then suddenly lose consciousness — by which I mean that the mannequin stops speaking and the eyes close," says Sara E. Hocker, M.D., a neurointensivist at Mayo Clinic in Rochester, Minnesota, who manages neurological simulations there. "The mannequin's pupils can react, and we can run fluid through it so that it has a pulse. The vital signs can change at any time, and the doctor has to react to that."

As the patient loses consciousness, nurses and respiratory therapists provide information and ask for instructions. Actors portraying family members react with distress and question the doctor; they may cry or start arguing with one another. Trainees may be required to quickly run through the informed consent process for administration of tissue plasminogen activator (TPA).

Effective communication with patients and their families is an important part of the simulations. "We want our residents and trainees to have experience with challenging interactions with patients and family members," Dr. Hocker says.

Scenarios may be videotaped so that young physicians can observe their body language. "We can point out that they didn't make eye contact with the patient or family, or maybe had a nervous fidget while speaking to them," says Christopher J. Boes, M.D., a neurologist at Mayo Clinic in Rochester, Minnesota. "The goal is not to stress out the trainees, but to get them to think through the process so that they provide better patient care."

Practicing surgical techniques

Special 3-D simulators allow surgeons to practice procedures before performing them on specific patients. One recent simulation at Mayo Clinic's campus in Florida involved a case of cavernous malformation in the brainstem. "We loaded the patient's MRI into the simulator and practiced the approach that would take us to the part of the brain where the lesion was closest to the surface," says Robert E. Wharen, Jr., M.D., a neurosurgeon at Mayo. "The simulator helps us to exactly plan the craniotomy. We can see not only the path to the lesion but also all the 3-D anatomy along the path."

Positive results

Trainees generally find simulations helpful. At an American Academy of Neurology meeting in 2012, Matthew T. Hoerth, M.D., a neurologist at Mayo Clinic's campus in Arizona, and Dr. Capampangan presented an abstract describing the results of pre- and post-simulation tests taken by trainees. Trainees' test scores — particularly trainees' knowledge of criteria for prescribing TPA — improved after participating in a simulation. "The verbal feedback from residents is that the scenario feels very real," Dr. Hoerth says.

Dr. Hocker still remembers lessons she learned from simulations during her fellowship at Mayo. "They stick with you. For me, simulations built confidence. They provide a safe opportunity for trainees to experience uncommon scenarios before they happen with real patients."

For more information

Capampangan D, et al. S3 neurologic education: Stroke education and patient education. Simulation based training for acute stroke alerts (P07.228). Presentation at: American Academy of Neurology Annual Meeting; 2012; New Orleans, La.