This study was conducted in July 2019 (endocrine session – pituitary case scenarios) and October 2019 (diabetes session – diabetes case scenarios), as part of a continuous professional and educational development for clinicians-in-training in Diabetes and Endocrinology in Health Education West Midlands (HEWM) deanery. All specialist trainee registrars specializing in Endocrinology and Diabetes or Metabolic medicine participated in the study.
SIMBA was based on interactive SBL through WhatsApp®. We initially identified five real-life case scenarios for endocrine and diabetes sessions. Following approval from specialists, anonymised transcripts were created on these case scenarios. These transcripts included medical history, clinical examinations, investigation results, imaging and other relevant information that would enable trainees to diagnose the case, propose management and follow-up plans. No patient identifiable data was included in the transcript. These transcripts were validated and approved by a consultant endocrinologist with specialist expertise to ensure that they portray real-life scenarios of respective cases. While the images used in endocrine session were approved by a consultant neuro-radiologist with a special interest in pituitary pathology, similar approval was obtained for continuous glucose monitoring and Libre readings for diabetes session (Fig. 1).
For endocrine session, standardized transcripts of five anonymized pituitary cases — Non-Functioning Pituitary Adenoma (NFPA), craniopharyngioma, macroprolactinoma, acromegaly and Cushing’s disease — were prepared. For diabetes session, standardized transcripts of four anonymized diabetes cases — interpreting Libre readings, interpreting continuous glucose monitor (CGM) readings, hypoglycaemic unawareness, and monogenic diabetes — were created.
In endocrine session, five moderators were chosen to participate in the study, whereas ten moderators were trained for diabetes session based on the feedback from endocrine session. These moderators acted as patient, senior clinician and multi-disciplinary team (MDT) liaison at different points of the simulation. Moderators familiarized themselves with the transcripts followed by at least three mock simulation sessions to ensure their proficiency. These moderators were then tested by the senior authors of the study to ensure there was no heterogeneity in the responses.
On the day of simulation, each moderator was assigned to a small group of trainees. All trainees brought their own computers/laptops/notebooks through which they were connected to the moderators via WhatsApp® Web application. Prior to initiating the simulation, the trainees were provided with the instructions shown in Fig. 2 via WhatsApp®. Once all trainees were ready, the simulation was initiated. If a trainee requested information that was unavailable on the transcript (e.g. ordering an inappropriate investigation or skipping a crucial step in diagnosis/management), they were prompted by the moderators that the information was not available or with appropriate advice to guide them back to the relevant step. During the endocrine session, the case scenario of non-functioning pituitary adenoma (NFPA) was run as a trial to allow participants to familiarize themselves to the simulation model. The case and its approach was then discussed in detail in line with current guidelines by an expert, which further helped the trainees to better understand the course of the simulation session. Following this, the trainees underwent simulation case scenarios for macroprolactinoma, craniopharyngioma, acromegaly and Cushing’s disease, followed by respective case discussions with consultant endocrinologist.
During the diabetes session, the case scenario of interpreting Libre readings was chosen as a trial similar to NFPA in endocrine session. This was followed by case scenarios for interpreting CGM readings, hypoglycaemic unawareness, and monogenic diabetes, followed by case discussion with relevant approaches in detail.
During these discussion, the consultant focused on the appropriate approach to the cases, in relation to the evidence-based international, national and local hospital guidelines as appropriate for each specific condition (15–21).
The confidence of the trainees (measured using a Likert scale ranging from strongly disagree to strongly agree) in approaching different pituitary and diabetes cases was assessed pre- and post-simulation (22,23). These data were then categorised into three groups: (i) confident: for those who responded with strongly agree and agree; (ii) not confident: for those who responded with disagree and strongly disagree; (iii) unsure: for those who responded with agree somewhat, disagree somewhat and undecided. The confidence levels of managing cases pre- and post-simulation are reported using frequencies, percentages, and are displayed in bar charts. Due to the nature of the data, Wilcoxon rank sum tests (significance set at p < 0.05) were deemed appropriate (using STATA MP/4 (Statacorp 2017)) to statistically compare confidence levels pre- and post-simulation. Significant tests are highlighted using an asterix.
Improvements in trainees’ confidence levels pre- and post-simulation of simulated scenarios (endocrine session – NFPA, craniopharyngioma, macroprolactinoma, acromegaly, Cushing’s disease; diabetes session - interpreting Libre reading, interpreting CGM reading, hypoglycaemic unawareness, and monogenic diabetes) vs. non-simulated scenarios (endocrine session – microprolactinoma, pituitary apoplexy, thyrotropinoma, gonadotropinoma, pituitary carcinoma; diabetes session - neuropathy, gestational diabetes, blood glucose meters, and ketone meters) were also displayed using frequencies, percentages, bar charts, and were also statistically tested using Wilcoxon rank sum.
In addition to views on the management of the cases, trainees were also asked to comment on their overall impression of the session, the consultant’s contribution during discussion and their interaction with the moderators.