Limitations
There are a few limitations that were identified in this study. Firstly, SBE is usually based on fidelity of the simulator in order to produce similar results of a real situation; therefore, it might be possible that the situation taught to the medical students couldn’t be reproducible in some clinical scenarios. Secondly, the lack of randomization of the groups and the volunteerism design of the study could have an effect on the results. Consequently, a selection bias could be present during student recruitment because students with higher academic performances may be more prompt to participate in any supplemental educational activity, including SBE, despite observing the lack of statistical difference (p=0.1372) of the MCAT scores from both groups. Lastly, an exploratory pretest-posttest including specific knowledge from the simulation experience was not conducted during the administration of the HFS, leading to the inability of assessing short term and long term knowledge specific for their simulation experience.
Generalizability
Several studies have demonstrated the equivalence or superiority of HFS as an educational technique to learning enhancement of a taught topic [1, 13]. A summary table of the debriefing evaluation HFS from this study is presented in Table 3. The results from our study are compatible with these results. Learning human physiology concepts in medical school has traditionally revolved around lectures and textbook memorization. While the traditional approach can be effective for many learners, HFS offers an alternative illustration of these concepts that appeal to visual, audio, and kinesthetic learners through multisensory engagement. Teaching physiology through HFS also achieves the goal of vertical curriculum integration, a blending of basic science principles with the clinical setting. While medical students generally embrace simulation as a learning method, the positive experience must be balanced with cost-effectiveness, time efficiency, and assessment results.
Simulation is usually reserved for clinical years of medical school; incorporating HFS to preclinical first-year medical students demonstrated that simulation is a feasible tool to integrate basic knowledge with clinical scenarios. Harris et al. evaluated first-year medical students’ knowledge and perception of cardiovascular physiology and congestive heart failure (CHF) treatment strategies. Comparing pretest and posttest scores of a six-question test after simulation demonstrated a 22% increase in correct answers (8). Similarly, Heitz et al. evaluated basic neuroscience concepts on 112 first-year medical students before and immediately after HFS through a four-question multiple choice test. After simulation, 83% of the participants scored the four questions correctly compared to 55% before simulation (6). In our study, instead of using simulation-related test scores, we used the scheduled block curriculum test to evaluate students’ knowledge acquired during simulation within a larger range of topics.
Additionally, instead of comparing same student pretest and posttest scores, our study compared students that participated in the SBE HFS scenarios with students only attending LBE as the control group to assess knowledge improvement after implementation of simulation scenarios. Likewise, Alluri et al. evaluated 20 second-year medical students attending simulation sessions and lecture sessions and compared pretest and posttest for each group. Both groups demonstrated significant improvement after the sessions (p=0.023 for SBE, p=0.001 for LBE), nevertheless, comparison between SBE and LBE groups was not performed, making our study unique (1).
Clear learning objectives must be defined when developing a simulation clinical scenario, focusing on diagnosis, management, and treatment of the targeted clinical situation. Morgan et al. evaluated 299 medical students after HFS that involved clinical scenarios resulting in unstable cardiac arrhythmia; learning objectives were recognition of anaphylaxis under anesthesia, management of anaphylaxis, and treatment of pulseless tachycardia (9). Our study focused HFS on physiologic concepts of pulmonary function; learning objectives were evaluation of pulmonary function without medical equipment, treatment of tension pneumothorax, and management of pulmonary function in the ICU.
Feedback from the simulation participants is essential to enhanced future scenarios and learning tools. Using a five-point Likert scale post-simulation, Heitz et al. showed that 97% of the participants agreed that HFS improved their learning of the neuroscience concepts (6). In the study performed by Harris et al., participants agreed that simulation helped them to learn cardiovascular curves (73%) and CHF treatment strategies (84%) (8). In our study, students who experienced the pulmonary physiology simulation not only confirmed they enjoyed learning through this method of teaching, but also outperformed their peers who did not participate in the sessions on the unit examination.
The investment in faculty time and resources is significant. However, we believe that the positive outcomes justify the expense, particularly since we anticipate that learning human physiology in the clinical context will save time and energy later on during the student’s clinical training. This curricular innovation has also allowed us to achieve a greater degree of vertical curriculum integration. While simulation has previously shown to be a useful tool for teaching basic physiology principles, our study further strengthens the case that high fidelity simulation, carefully scripted to provide a rich clinical context, enhances medical student understanding of basic pulmonary physiology concepts through multisensory engagement [1, 7-10].
High-fidelity human physiology simulation equipment and qualified technical support staff requires significant institutional monetary investment. We also found faculty support and preparation to be critical to the success of this simulation session. Well trained instructors were needed to maintain the flow of the simulation session, illustrate key teaching points, be prepared to adapt to the varied reactions of the learners, and answer questions.
One option that could be explored is whether similar learning gains would be observed if students watched a recording of this session in lieu of live participation. This could be a study design option for future research that could possibly save faculty and technical resources.