ERC Resuscitation 2019 – How should we train

Last week I had the great pleasure of speaking at the ERC resuscitation congress in Ljubljana, Slovenia.

Not anticipating the extreme stress of applying for my specialty training position (got it!), I had happily accepted two talks. One tried to answer how we should train in resuscitation and another how to share your ideas through lectures. Both lectures were, by the way, placed in sessions with one of my sponsors, mentors and good friends Simon Carley from Manchester where the conference will be next year. He is of course also the editor of St. Emlyn’s. Go check out the blog and podcast – you’ll find plenty of resus-related posts.

Back in 2016 I spoke at SMACC and from my talk “How students can choreograph their own education” came a tweet that reached far, quoting me for saying “Go to the sim like you go to the gym”, a phrase people still come up to me and quote and tell me how much they like and relate to.

Ever since, I have wanted to do a talk where I could reuse and elaborate on that idea.

So when I was asked to speak on how we should train in resuscitation, I decided to in that talk do a comparison with going to the gym.

The Problem

It’s not that I’ve discovered anything revolutionary about resuscitation training. To be fair, we already know quite a lot about how learning and memory works, so for successful training in resuscitation we should look to what we already know from learning theory.

Despite this knowledge about learning and an abundant literature and research base on resuscitation training, though, gaps still exist in delivering optimal care in resuscitation. We train million of lay and healthcare providers each year around the world and we still suffer from decay of skills learned at courses, rapidly after attending. With the result of a lack of transfer of education and research knowledge to the clinical environment.

The American Heart Association has published a scientific statement paper by Cheng Et al that covers most of what is in this post so go there if you want an extensive (30 pages + references) in depth look(1).

The aim of my talk was to try and translate some important messages from learning theory into something more easily understandable…… like going to the gym, and in that way try and change behaviour to support long term retention of learning, and in the end help secure good patient outcomes.

Work intensely on the hard stuff

When you go to the gym you sometimes increase the weight to build more muscle and see how strong you really are. The same for resuscitation training. Sometimes, we have to increase the difficulty of what we are doing and build resuscitation muscles by pushing ourselves a little more. We have to do that, because easier isn’t better when it comes to learning. In fact, if you don’t increase difficulties you get lazy and forget because you don’t have to put in an effort.

When we increase difficulties, we of course have to pay attention to how much stress it adds and aim for desirable difficulties. That’s Vygotsky’s theory of training in the zone of proximal development where just enough effort is required that the task can be performed with a little bit of guidance and coaching and not so overwhelming it creates too much stress and frustration and prevents learning altogether.

When people attend resuscitation courses, many are standardised courses where we don’t really know if we challenge or overload the participants and desirable difficulties can be hard to achieve. To fix that, making use of the flipped classroom where people can read and watch online material beforehand can add some much needed preparation and help for novices and adapting to participants background at the course in both workshops and scenarios can add or subtract some difficulties for learners depending on their knowledge level, experience and expertise. We may not always be good at this, but to keep our adult learners motivated we should pay close attention to this and get to know what level people are at and what they want to and are ready to improve on.

Activate your brain

When we train, we should incorporate interval training (interleave topics and subjects) and space training out.

If you do the same exercise every time you go to the gym, your training stops working and the outcome you expect will not happen. It’s the same with learning. If you study one topic and one topic only you will probably feel confident you know everything you need to know about that topic, but the truth is that your learning gets fragmented and will not stick well to your brain, because we learn from mixing things up and spacing it out.

Let’s say you wanted to get good at basketball – and the test I would give you in 4 weeks would be to get the ball in the basket from a distance of 15m. You could go about it in 2 ways: Throw the ball from a distance of 15m 8 hours a day for 4 weeks. Or, train your throw from distances of 12m and 18m. If you choose option 2 you would be significantly better on test day. You probably wouldn’t believe me and I might struggle to convince you to continue this way of training because most learners prefer blocked learning instead of interleaving. Nonetheless, that is the better way to train or learn if you want the best results.

When you study the heart you know you learn important things about the heart and the blood pressure from studying the kidney. Also, studying topics by interleaving makes you forget some of what you studied earlier on. When you revisit it, you realise that not all was consolidated into long term memory and you need to work harder to further activate your brain and memory. That way testing becomes what it is really useful for – a way to strengthen retrieval and a study guide to make you keep repeating the things where you have to put in a little more effort, to ensure memory activation and storage. Interleaving and spaced repetition also trains your discrimination skills – in medicine that’s our differential diagnosis skill so pretty important to keep this muscle well trained.

Interleaving and spacing out training can seem difficult at resuscitation courses. Especially because we don’t know exactly how much space is needed between sessions. Again, retrieval practice of what is known is good for experts who don’t need much space between session and cope very well with the frequent repetition and mix of topic presented at e. g an ALS course. Novices, however, may feel overloaded with the frequent shifts of topic alternating between ECG and ABG interpretation mixed up with alternating resus-scenarios, without much time to digest and reflect on what is learned. A fix, again, would be to continuously develop more online material on the covered material so topics can be spaced out with enough time for repetition and retrieval practice before actually attending the course.

Get a Coach

Some things can be worked out on your own. Other things require a team or a coach.

Sometimes when you’ve been working out some time on your own, your bad techniques and suboptimal performance goes unnoticed. The sentence “practice makes perfect” is not anymore true for medicine than for music and sports. Therefore, you should get a coach that can help you make sure you keep increasing your abilities by using deliberate practice and mastery learning.

To truly master a skill means that a learner can consistently demonstrate a specific level of competence at a specific skill. By deliberate practice we understand activities specifically designed to improve the current level of performance. From that definition, it is clear that training isn’t just training. In deliberate practice and mastery learning you train with a knowledge of who and where your learner is (baseline testing), you state (and have made) clear learning objectives with desirable and increasing difficulties as your learner improve. You train with a strategy and tool that supports reaching that goal (functional task alignment – we sometimes are not very good at this!), and you set a minimum passing score for each difficulty so that you know if and when your learner is ready to advance. You test, and test, and test – because testing is good for learning and you test people against a standard that equals the predefined mastery learning standard (again, testing isn’t just testing, tests have to be carefully planned). By following those steps you can train deliberately, by identifying weaknesses and design specific interventions to improve performance for the learner and outcome for the patient. Time is a keyword here, as is continuous assessment. All of which can be difficult to implement into a standardised course. The solution, again, might be flipping the classroom so that learners can watch videos well in advance of a what mastering a required skill looks like before arriving at the course day. Time… well education takes time. Some need a little extra time on some topics and should be given just that.

We know from resuscitation training that this works (2). And from music. And from sports. And school kids. Nothing new, not rocket science, pretty logical that it’s not about the repetition, but the feedback and evaluation you get along with it.

Some things can be worked out on your own. Some examples of self-repetition of basic life support skills already exist in resuscitation, but: By alone I don’t necessarily mean without feedback that may very well come from the equipment in which case it can be done successfully without the presence of an instructor or others.

Other things have to be worked on in teams. Here I am talking about the whole groups of skills related to leadership, followership, communication and teamwork. It’s difficult to train leading a team on your own. In the future this may be solved by virtual reality, but for know that’s why in situ simulation or inter-professional training at the sim lab are so popular.

We love working out with the people we work with in real life. Whether is has to be done in situ or the sim lab, the evidence isn’t fully clear yet, but training in context does have some benefits in terms of helping to identify safety threats within an organisation. That of course shouldn’t be ignored. For practical advice on how to train your resus team you definitely shouldn’t miss out on this FOAMed resource from Cliff Reid et al on Zero Point Survey (3) (open access here)

We also like working together with others because we are social animals that learn in social context. Which leads nicely to the next topic.

Learning conversations – to learn, reflect!

You may not debrief most of your gym sessions, but I bet you, you’ve been online more than once to find out how others train, discussed in online forums about the best way to learn running, or had a chat with a co-worker about how they train to stay healthy and fit. And that’s because we learn from reflection, elaboration and calibration. In a conversation with others we calibrate our own knowledge, we elaborate on topics to find out how much we really know and what we really think about a topic. When we or others elaborate, we learn from their point of views and the knowledge they add to the conversation filling out our own knowledge gaps. Finally, we avoid the illusion of knowing by being corrected in knowledge we generate that might be wrong or misunderstood, and we get better from getting corrected by instructors or peers.

I gave a word of caution on feedback in my talk. On many resuscitation courses the time for learning conversations and reflection is short. Often too short. And when that happens, we have a tendency to resort to feedback. Feedback is good – I am not talking about the good constructive useful feedback here. But the direct feedback we sometimes resort to when time is short at courses and we forget that learning from being told is a flawed strategy (4). Adult learners are intelligent learners, that show up to work and courses every day wanting to do their best. When we try to correct their behaviour by telling, without having asked for their motivations and reasons for doing what they did, we are often met with rejection of the feedback. That means, that if you haven’t established that safe educational alliance with the learner, feedback may easily be received as poorly delivered, off base, corrective and negative (no matter how true it is) and be extremely counter-productive for learning. The fix? Make sure you allow time for learning conversations.

Barriers to training

In the final part of this talk I presented the usual barrier suspects…. time, money and equipment.

Truth is, in most systems today, time is the resource we lack most. And I don’t know how to fix it. When it comes to mandatory job-related training, time should be allowed and paid for by the employer. Just because learning can take place online, it doesn’t mean that learners should meet job requirements on their own time. Secondly, all evidence shows that learning takes time. I have yet to read a study with strong evidence that time can be cut for learning. Time can be better spent for learning as described in this post, but we need time. Time for training, time for retrieval, time for interleaving and spacing and time for reflection. Ergo. Learning takes time. And the segment of our employers who thinks they can make us cram and block learning together are wrong and should be forwarded this post along with the references. Money and equipment (incl instructor resources) are definitely a shortage in some of our systems and we should continuously work with industry to develop gaming, different artificial intelligence solutions and equipment that, at least for some skills, can take over on giving feedback and allow for frequent training without an instructor present.

Bottom line

In or out of the sim – you should resus like you go to the gym. Happy resuscitation training.

Vb/ Sandra

References

1: Cheng A, Nadkarni VM, Mancini MB, Hunt EA, Sinz EH, Merchant RM et al. Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association.
Circulation. 2018 Aug 7;138(6):e82-e122.

2: Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, Bradshaw JH,
Diener-West M, Perretta JS, Shilkofski NA. Pediatric resident resuscitation skills improve after “rapid cycle deliberate practice” training.
Resuscitation. 2014 Jul;85(7):945-51. doi: 10.1016/j.resuscitation.2014.02.025.
Epub 2014 Mar 4.

3: Reid C, Brindley P, Hicks C, Carley S, Richmond C, Lauria M, Weingart S. Zero
point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness.
Clin Exp Emerg Med. 2018 Sep;5(3):139-143.

4: D. Royce Sadler. Beyond feedback: developing student capability in complex appraisal, Assessment & Evaluation in Higher Education.2010 35:5, 535-550

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Sandra Viggers
Star skater, simulationista by day , anaesthesia by night and #meded choreographer. Coming to a SIM room near you. With a shark.
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Signe Kähler

I wonder wether “interweawing” would be a better word than “interleaving”? :-)

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AUH, "Rejseholdet" - Resus training team.