Simulated Patient as a Learner: Medical Volunteers Gain Knowledge by Participating in a Wilderness Medicine Training Session

Abstract

Introduction

A multifaceted approach to wilderness medicine education and training is necessary to provide a high-quality learning experience, often requiring innovative instructional techniques. Using volunteers to act as patients in medical education is a well-established practice that helps teach crucial skills. However, more is needed to know if there is potential knowledge acquisition through participation. This study examined the educational benefits for medical students serving as a simulated patient (SP), hypothesizing that these individuals will improve self-assessed knowledge and confidence and demonstrate improved performance of injury-management skills while participating in a medical education course.

Methods

A descriptive feasibility pilot study was conducted with 10 SPs to assess knowledge and skill acquisition. Study participants were evaluated before and after participating as an SP in 2 scenarios involving hemorrhage control and wrist injury assessment and management, with a subjective confidence survey and an objective skill and knowledge demonstration, as measured by a critical action checklist.

Results

The subjects all reported self-assessed knowledge improvement from the pre- to postintervention survey, with an average increase of 17 points. They also demonstrated improved objective skill and knowledge demonstration, with an average increase of 4.6 points for the wrist injury scenario and 2.5 points for the hemorrhage control scenario.

Conclusions

This study demonstrated that volunteer medical students acting as SPs in a medical training course passively acquire knowledge and improve their medical skills and self-perceived confidence. The findings contribute to a broader understanding of medical education, suggesting that participating as SPs offers educational benefits. The results encourage consideration of simulated patient roles as a valuable adjunct to medical education, warranting further scholarly exploration to substantiate and expand on these preliminary findings.

Keywords

wilderness medicine medical education patient simulation outdoor education first aid

Introduction

Wilderness and austere medicine requires teamwork, critical thinking, and the ability to provide emergent stabilization.¹ The unpredictable conditions in an austere setting involve assessing and treating traumatic injuries and medical illnesses while managing additional environmental and logistical situations. A multifaceted approach to wilderness medicine education and training is necessary to provide a high-quality learning experience, often requiring innovative instructional techniques.

The use of simulated patients (SPs) is a well-established practice in medical education to help teach a broad range of crucial skills, including, but not limited to, history taking, communication, medical management, and basic procedural demonstration.^2–4 It should be noted that these volunteers are not standardized patients because there is no formal training, and they do not meet the criteria of this term. Although they are not the target learners in these educational experiences, SPs learn by interacting with the participants, preparing themselves to exhibit appropriate physical exam findings, and responding to questions regarding their chief complaint. They are also passively exposed to the thought processes and teamwork displayed by those working through the educational event with the lead educator. Despite the extensive use of SPs in medical education, more data must be collected to evaluate the knowledge gained by learners acting as SPs. This pilot study aimed to contribute to the broader understanding of SP learning experiences and their potential role as an intentional tool in medical education. We hypothesized that the medical students who act as SPs on the testing day of a 2-d wilderness medicine course will passively learn critical aspects of injury management.

Methods

This descriptive pilot study assessed the knowledge and skills acquired by medical students volunteering as SPs in a wilderness medicine course in November 2023. Ten medical students were enrolled with the expressed understanding that they would be volunteers for the course and study participants. The group was a mix of second-, third-, and fourth-year students. Two individuals had prior wilderness medicine experience but were not excluded from the study. The demographic information was used to protect each participant's identity and track participants through the study. They were blinded to what tasks they would be evaluated on during the study, and they did not complete the initial required coursework or classroom education provided to the enrolled course participants. The project was determined to be exempt from review by the institutional review board.

It was predetermined that the participants would be assessed on their knowledge and skills to manage hemorrhage control and a wrist injury. They acted as SPs in 3 separate testing scenarios for those enrolled in the course, in which evaluation and management of these skills would be required interventions to pass the scenario. Study participants were assessed on these skills before and after participation as SPs through a written survey and a demonstration of skills. The selection of both these assessment methods was intentional so as to demonstrate higher levels of participant knowledge acquisition, including knowledge, comprehension, and application according to Bloom's taxonomy.⁵

Participants completed a preintervention subjective self-reported confidence assessment of their ability to perform skills by completing a Likert-style survey asking them to rank their confidence levels on a scale of 1 (strongly disagree) to 10 (strongly agree), as shown in Figure 1. An identical survey was administered after their experience as SPs to evaluate the change in their self-confidence about their ability to complete the tasks. One question was added, asking the SPs to rate the overall enjoyment of the activity in the postintervention survey.

To objectively assess their knowledge and skill acquisition before acting as SPs, study participants were evaluated on their preintervention abilities to properly assess and manage an acute hemorrhage and wrist injury by completing scenario-critical actions. The scenario instruments were investigator developed using previous templates for case presentations with modifications. The critical actions were then reviewed and refined through an iterative process. Two of the study authors administered the testing. They were both trained on appropriately scoring the SPs and ensuring the capture of all completed or noncompleted critical actions. They were given a script to follow and were not allowed to help or answer questions during each scenario, including disclosing the critical actions. Each completed critical action received 1 point, no partial credit was given, and no feedback was provided. After participating as SPs during the entire course, study participants were reevaluated with the same scenarios, scripts, and critical actions. Figure 2 displays the scripts and critical actions used for this assessment. Pre- versus postintervention counts of completed critical actions were compared for both scenarios using the Wilcoxon signed-rank test. Correlation in improvement in the number of completed critical actions for the 2 scenarios was evaluated using Spearman's correlation coefficients.

Results

Every study participant completed the surveys and demonstrated improvement in subjective self-reported confidence and skills after the intervention. Table 1 outlines the pre- and postintervention subjective self-reported confidence and knowledge improvement, with Figure 3 graphically displaying the increased self-reported confidence. The average self-reported confidence before participation as an SP was 15.7 across all 10 participants. It increased to an average of 32.7 after participation, with a minimum increase of 6 and a maximum increase of 39. Although the average confidence increased in the whole group, third-year medical students acquired the most overall confidence. The increase in overall level of confidence for the hemorrhage control and wrist injury scenarios were both significant (signed-rank P=0.002).

Table 1.

Pre- and postintervention subjective knowledge and postintervention subjective value in experience.

Participant	Preintervention					Postintervention						I found learning as a volunteer victim a valuable experience
Participant	Q1	Q2	Q3	Q4	Total	Q1	Q2	Q3	Q4	Total	Total increase
1	0	0	0	0	0	10	9	10	10	39	39	10
2	5	5	6	4	20	9	9	10	10	38	18	10
3	1	1	2	3	7	2	3	4	4	13	6	10
4	5	2	8	5	20	8	8	5	8	29	9	10
5	6	4	3	2	15	8	8	9	9	34	19	10
6	5	4	5	5	19	9	9	8	9	35	16	10
7	6	6	7	6	25	9	9	9	9	36	11	10
8	1	1	7	6	15	10	10	10	10	40	25	10
9	5	5	3	3	16	8	10	8	10	36	20	10
10	6	4	6	4	20	7	6	8	6	27	7	7

Q, corresponding question in the self-reported confidence questions (see Figure 1).

The objective demonstration of skills and knowledge in the wrist injury and hemorrhage control scenarios also improved for both scenario stations. Table 2 outlines the hemorrhage scenario pre- and postintervention critical action scores, and Table 3 demonstrates the same information for the wrist injury scenario. The average (median) number of completed critical actions for the wrist injury scenario increased from 0.6 (0) before the SP experience to 5.2 (5.0) after. This improvement in the median number of completed critical actions for the scenario was significant (signed-rank P=0.002) because there was an improvement from the initial score of zero. The average (median) number of completed critical actions for the hemorrhage control scenario increased from 3.2 (2.5) to 5.7 (6.0) after the intervention. This improvement in the median number of completed critical actions for this scenario also was significant (signed-rank P=0.004). All participants increased their total improvement in both scenarios except 1 participant who demonstrated no increase in their numerical improvement in the hemorrhage control scenario. The improvement in the number of completed critical actions for the 2 scenarios was mildly correlated (ρ=0.378; P=0.28), indicating that the respondents with better improvement in the number of completed critical actions in the wrist injury scenario also were likely to have a higher number of completed critical actions in the hemorrhage control scenario (and vice versa).

Table 2.

Hemorrhage control scenario pre- and postintervention objective skills testing results and total improvement.

Participant	Preintervention								Postintervention								Total improvement
Participant	CA1	CA2	CA3	CA4	CA5	CA6	CA7	Total	CA1	CA2	CA3	CA4	CA5	CA6	CA7	Total	Total improvement
1	yes	yes	no	no	no	yes	no	3	yes	no	yes	yes	yes	yes	yes	6	3
2	yes	no	yes	no	no	no	no	2	yes	no	yes	yes	yes	yes	no	5	3
3	yes	yes	yes	no	no	yes	no	4	yes	yes	yes	yes	yes	yes	yes	7	3
4	yes	no	yes	no	no	no	no	2	yes	yes	yes	yes	no	no	yes	5	3
5	yes	no	yes	no	no	no	no	2	yes	no	yes	yes	no	no	yes	4	2
6	no	no	yes	no	no	no	yes	2	yes	no	yes	yes	no	no	yes	4	2
7	yes	yes	yes	yes	yes	no	yes	6	yes	yes	yes	yes	no	yes	yes	6	0
8	yes	no	yes	no	no	no	yes	3	yes	yes	yes	yes	yes	no	yes	6	3
9	no	yes	yes	no	no	no	no	2	yes	yes	yes	yes	yes	yes	yes	7	5
10	yes	yes	yes	yes	yes	no	yes	6	yes	yes	yes	yes	yes	yes	yes	7	1

CA, critical action

Table 3.

Wrist injury pre- and postintervention objective skills testing results and total improvement.

Participant	Preintervention											Postintervention											Total improvem-ent
Participant	CA1	CA2	CA3	CA4	CA5	CA6	CA7	CA8	CA9	CA10	Total	CA1	CA2	CA3	CA4	CA5	CA6	CA7	CA8	CA9	CA10	Total	Total improvem-ent
1	no	no	no	no	no	no	no	no	no	no	0	no	no	yes	no	yes	no	no	no	yes	yes	4	4
2	yes	yes	yes	no	no	no	no	no	no	no	2	yes	yes	yes	no	yes	no	yes	no	yes	no	6	4
3	yes	no	no	no	no	no	no	no	no	no	0	yes	yes	yes	yes	no	yes	yes	yes	yes	yes	9	9
4	no	no	no	no	no	no	no	no	no	no	0	yes	yes	yes	no	no	no	no	yes	yes	yes	6	6
5	no	no	no	no	no	no	no	no	no	no	0	no	no	no	no	yes	no	yes	no	no	no	2	2
6	no	no	no	no	no	no	no	no	no	no	0	no	yes	no	no	yes	no	no	no	no	no	2	2
7	no	yes	no	no	no	no	no	no	no	no	1	no	yes	yes	no	no	no	no	no	yes	yes	4	3
8	no	no	no	no	no	no	no	no	no	no	0	no	yes	no	no	yes	no	yes	no	yes	no	4	4
9	yes	no	yes	no	no	no	no	no	no	no	1	yes	yes	yes	no	yes	no	yes	yes	yes	no	7	6
10	yes	no	yes	no	yes	no	no	no	no	no	2	yes	yes	yes	no	yes	no	yes	yes	yes	yes	8	6

CA, critical action

Discussion

To our knowledge, this project is the first investigation to demonstrate subjective and objective learning by medical students acting as SPs in a wilderness medicine training course. Similar beneficial passive learning may be hypothesized for other hands-on wilderness medicine skills that use SPs for teaching, including point-of-care ultrasound, case-based simulation exercises, and team leadership.

The survey data of self-reported confidence show an average increase of 17 points overall, almost doubling in subjective knowledge acquisition. This finding is concordant with the average increase in the critical actions completed, indicative of an actual increase in knowledge and skill. Overall, there was an average 4.6-point increase in the wrist injury scenario and a 2.5-point increase in the hemorrhage control scenario. In both clinical scenarios, the study participants, on average, completed a similar number of critical actions. However, in the wrist injury scenario with more critical actions to complete, the preintervention scores were lower than those of the hemorrhage control scenario. Although these findings are significant, future studies could use other active learning strategies to measure the effect, including deliberate practice, facilitation, debriefing, and feedback to evaluate for more robust knowledge acquisition or long-term retention.

This study evaluated medical students in their first through third years of training. Although they may have baseline scientific knowledge and some clinical exposure, first- and second-year medical students generally have not started their clinically focused studies or rotations, suggesting that passive learning took place even without a significant clinical background. While we asked for medical student year level and previous wilderness medicine experience, there was no standardization of previous medical experience or incorporation of medical training from the different medical schools where the SPs were enrolled. Additionally, prior experience in the medical field (eg, EMT, paramedic, nursing, or other advanced training) was not collected. As a result, previous experience may have affected their performance. Further demographic information would be helpful in future studies to identify additional trends or associations.

A significant limitation of this study is that the small sample size limited advanced statistical evaluation. Further studies, including much larger sample sizes and information from different courses with different teaching methods, could be included in future publications to provide a more thorough evaluation. The small sample size also limited our ability to standardize the sample and account for confounding factors. Finally, with additional participants, the assessment could be performed with additional non-SP study subjects to add a control group. This would allow for advanced statistical evaluation and a more robust demonstration of educational benefit.

Another limitation is that participants were aware of the tasks they were being evaluated on after completing the preintervention skills demonstration. This protocol feature may have allowed participants to focus more intently on wrist injury assessment and management as well as hemorrhage control while acting as an SP. To mitigate this a priori limitation, the critical actions and case script used in the SP pre- and postintervention testing were not used in the course testing scenarios where the medical students acted as SPs. In addition, instructions were provided to the course participants, and significant care was taken by the course instructors not to provide additional explanatory information to the study participants before taking the postintervention skills test. However, despite these interventions, an SP cannot be completely blinded to the educational content after preintervention testing, and it is thus a source of potential bias.

Conclusion

Medical students who assisted as SPs in a wilderness medicine course obtained medical knowledge by objectively improving their ability to demonstrate medical care tasks and understand key aspects of injury management through a passive learning process. Larger studies are needed to provide a more extensive statistical analysis and further elucidate the educational objectives that can be met through this teaching modality. This information could be used to enhance curricula in other aspects of wilderness medicine education, thereby improving the preparedness of medical professionals to handle diverse and challenging scenarios through targeted enhancement of the learning experience.

Footnotes

Author Contribution(s)

Geoffrey Comp: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Supervision; Writing – original draft; Writing – review & editing.

Michael Foggia: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Writing – review & editing.

Cody Blentlinger: Conceptualization; Data curation; Investigation; Project administration; Writing – review & editing.

Bikash Bhattarai: Data curation; Formal analysis; Writing – original draft; Writing – review & editing.

Cornel Popescu: Conceptualization; Data curation; Investigation; Project administration; Writing – review & editing.

Andrea Ferrari: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Supervision; Visualization; Writing – original draft; Writing – review & editing.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval

The project was deemed exempt from review by the Valleywise Health Institutional Review Board on October 18, 2023 (Protocol ID 2023-083).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Geoffrey Comp

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