Simulation in Medical Education

The greatest cause of human disease is human culture, and the solution is to change that culture and the way we live. It has nothing to do with animals. A medical industry dedicated to animal research is corrupted by cruelty and cannot be a truly healing profession.

This paper presents the development of a mobile Augmented Reality (AR) heart rate murmur simulator that can be used for clinical teaching for medical trainees. Traditional medical training often requires the trainees to have hands on experience with real patients. However, it is not often possible to find certain types of heart murmurs with patients available for training. To overcome this limitation, we have developed a wearable clothing system using mobile audible AR that provides heart murmur simulation for facilitating medical learning experience. In this paper we describe the proposed system, a user evaluation study and directions for future work.

Introduction: There is global support for the teaching of cardiopulmonary resuscitation (CPR) in schools, and teachers are expected to play a leading role in a medical emergency. For effective resuscitation, retention of CPR knowledge after training is paramount. This study aimed at assessing the retention of CPR knowledge among student teachers at pre-, post-immediate, 8th-, and 14th-week post-training. Method: A quasi-experimental study using non-probability convenience sampling was conducted to select 41 respondents from the Department of Physical and Health Education , Faculty of Education (UiTM). A validated American Heart Association's 2015 Basic Life Support (BLS) multiple choice questions (MCQ) were utilised to measure the retention of knowledge among the participants. Results: This study demonstrated a significant lack of CPR knowledge during pre-test with the mean scores of M=8.02 despite half of the participants had prior knowledge in CPR. Nevertheless, the paired t-test revealed a significant improvement in the post-scores following the intervention at M=16.20, t(40) =-18.56, p < 0.001, and d=3.91. The one-way RM-ANOVA results showed a decline in the retention rate at the 8th week (M=13.06; p < 0.001) and an improvement at the 14th weeks (M= 5.74; p < 0.001). Conclusion: The knowledge of CPR among the student teachers following the intervention program was appropriate, but the deterioration of retention suggested that all student teachers should undergo comprehensive routine CPR courses to avoid the immediate loss of CPR knowledge and skills. The governing bodies in Malaysia should implement CPR training as part of the curriculum for teachers.

"Background: Theconcept of simulation as an educational tool in Emergency Medicine is becoming commonly used.
Aims: Developing a simulation-based course appears to be the best way for EM learning and improving patient safety. Teachers should know why simulation techniques are useful in adult learning and at what stage they should be included in the curriculum. This highlights the need for a clear statement of benefits and limitations of medical simulation.
Method: This paper is the outcome of the medical simulation and education workshop that was designed for the 1st Global Network in EM Conference held in Dubai in January 2012.
Results: This paper presents a clear classification of educational scheme in adult medical learning and its benefits in understanding the need for EM in training using teamwork for risk reduction and better health care. There are different ways to teach in simulated environment and it should be in combination with traditional methods. Essential factors for the success of simulation-based education in- clude providing feedback and staff training, integrating simulation into beginning and continuing training and providing repeated practical situations with variable levels of difficulty and setting.
Conclusion: In emergency medicine context, Simulation is helpful for guiding educators and trainees to realize the po- tential learning outcomes in professional development. Simulation improves EM quality of care."

This article examines the clinical staging of simulations using actors to perform as standardized patients (SPs) in a nursing simulation laboratory. Detailed multimodal analysis of video-recordings of SP training shows how the perceiving body of standardized patient is transformed as a map that systematizes, organizes, and classifies novices’ knowledge into a unified system of clinical practice. I develop a “gesture-touch clusters" framework to illustrate how embodied practices are mobilized as a systematic activity to provide scaffolding for the performance of standard nursing interventions. By calling attention to mapping the use of clinical practice onto the live body of the standardized patient this article considers standards as residing in the bodily and interactive practices, not in their discursive articulations in clinical scripts, protocols, and checklists.

"Simulation is becoming more and more popular in the field of healthcare education. The main concern for some faculty is knowing how to organise simulation training sessions when there is no simulation centre as they are not yet widely available and their cost is often prohibitive. In medical education, the pedagogic objectives are mainly aimed at improving the quality of care as well as patient safety. To that effect, a mobile training approach whereby simulation-based education is done at the point of care, outside simulation centres, is particularly appropriate. It is usually called “in-situ simulation”. This is an approach that allows training of care providers as a team in their normal working environment. It is particularly useful to observe human factors and train team members in a context that is their real working environment. This immersive training approach can be relatively low cost and enables to identify strengths and weaknesses of a healthcare system. This article reminds readers of the principle of « context specific learning » that is needed for the good implementation of simulation-based education in healthcare while highlighting the advantages, obstacles, and challenges to the development of in-situ simulation in hospitals. The objective is to make clinical simulation accessible to all clinicians for the best interests of the patient.

La simulation en santé gagne en popularité dans le champ de l’éducation médicale. La préoccupation des formateurs en simulation est de savoir comment proposer des séances de simulation en santé alors que les centres de simulation ne sont pas encore répandus et que leur coût paraît prohibitif. Or, en formation médicale, les objectifs pédagogiques s’orientent principalement vers l’amélioration de qualité des soins et la sécurité du patient. Par sa mobilité, la simulation in-situ est une simulation réalisée « au pied du lit » (point of care), en dehors des laboratoires de simulation. Elle apparaît donc comme une méthode originale qui permet d’entrainer les soignants, en équipe, dans leurs conditions de travail habituelles, afin de mettre en jeu les facteurs humains et faire évoluer les apprenants dans un contexte proche du réel. Tout en identifiant les forces et les faiblesses d’un système de soin, cet entrainement en immersion permet également de réaliser une simulation de haute fidélité à moindre coût. Cet article rappelle le principe de « contextualisation » nécessaire au bon déroulement de la simulation et met l’accent sur les avantages, les obstacles et les défis au développement de la simulation in-situ dans les hôpitaux. Le but est de rendre accessible la simulation en santé à tous pour le bien des patients."

Le Centre d’Enseignement des Soins d’Urgence est historiquement “l’école des SAMU“ (Services d’Aide Médicale Urgente). Le CESU contribue à la formation initiale et continue des professionnels de santé face à l'urgence. Grâce aux nouvelles techniques pédagogiques mises en œuvre, avec notament la simulation en santé, leur implantation au sein des établissements de santé est non seulement un atout pour le développement professionnel continu (DPC) mais se révèle aussi un outil indispensable à la prévention et la gestion des risques. Grâce à leur réseau créé en intra et extra hospitalier, les CESU représentent une plus value en terme de coordination des soins et probablement en terme financier. Que ce soit en France ou au Mahgreb, ils se profilent comme des acteurs potentiels de l’évaluation des pratiques professionnelles et de la recherche médicale.
[The CESU (Center for EMS Education) is historically “the school of SAMU” (Emergency Medical Services). This center contributes to the initial and continuous training and education for health professionals facing emergencies. Throughout new teaching techniques implemented, especially with simulation in healthcare, their implementation in healthcare facilities is not only an asset to the continuing professional development (CPD), but also turns out to be an essential tool for risk prevention and management. Through their network established within and outside the hospital, this “learning”
center represents an added value in terms of coordination of care and probably in financial terms as well. Whether in France or Maghreb, they are emerging as potential actors in the evaluation of professional practice and medical research.]

There is enormous evidence that the initiation and growth of atherosclerosis is highly influenced by hemodynamic factors. In this study, hemodynamic factors in the following patient specific 3D carotid artery models were studied: i) normal, ii) stenosis (with plaque near to bifurcation of internal carotid artery (ICA)), and iii) surgical model (plaque with surgically fitted Palmaz–Schatz stent). The 3D model of the carotid artery was formed from CT image of a patient through a commercial software MIMICS. The geometrical measurement taken from the 3D model was used to form its CAD model using CATIA software. The CAD model was meshed in ANSYS ICEM CFD module. The inlet- and outlet- boundary conditions were defined and material properties were given in CFX-Pre module of ANSYS. Then the solver input file was given to CFX solver manager for performing computational fluid dynamics (CFD) on the model. The outputs of the CFD analysis were observed in CFD-Post. The wall shear stress and blood velocity were greater both at near the bifurcation and at bend of the carotid artery model. The abnormal model is characterized by high wall shear stress in the stenosed portion which indicates greater probability of growth of plaque. Disturbed flow patterns and oscillating velocity indicate that the vulnerability of plaque formation is high in such places. The hemodynamic values have come back near to normal values in the carotid model fitted with stent. The observed variations in hemodynamic factors in the carotid artery with plaque surgically fitted with stent were compared to its normal model. This information can be used to predict restenosis in future.

this is a timely book in the age of vertiginous technological advances in the field of medicine. the author Dr. Herbert Ho Ping Kong makes his observations from the perspective of a clinician who has been practicing internal medicine for fifty years spanning three continents.

Purpose of Review
Anesthesia workforce gaps in low-and middle-income countries (LMICs) can hinder safe surgical care. Several countries have fewer than one anesthesiologist per million population and some have fewer than two anesthesiologists nationally. Limited apprenticeship opportunities and inadequate supervision present serious challenges in these locations. Although simulation training could help disseminate expert guidance, the high cost, technical challenges, and varied approaches limit application. We reviewed the literature on cost-efficient and effective simulation training programs for anesthesia workforces in LMICs. Recent Findings Publications relevant to anesthesia simulation in these countries are limited but include anesthesia skill gap identification, technical skill training, and scenario management.

Summary
High-cost, high-technology simulation available in high-resource countries is often impractical in LMICs. We identified low-cost approaches that are typically used to assess skill deficiencies and develop nontechnical and technical skills. Future studies should evaluate optimal modalities and equipment for greatest impact.

Through 2005 a new simulation pediatric centre linked to
the Faculty of Medical Sciences (The New University of Lisbon) became effective at Dona Estefânia Hospital,
Lisbon. The main innovation was concerned with the
opportunities of simu lation procedures practice devoted to
the 5 th year medical students using manikins. This study
aimed to describe the functioning of the mentioned learning
– teaching setting and to assess the feedback and suggestions from the trainees and trainers as a keystone of future
planning.
All the trainees regarded this training model as very relevant
for their apprenticeship as a complement of clinical practice
with real patients. Most of them expressed the need for high
amounts of time available for the training and for more diversity of manikins. According to the trainers experiences there
is a need to improve some logistic issues and to maximize the
facilities opening this setting to the post-graduation trainees
whose implications are to improve the protocol rules between
the faculty and the hospital.
In summary, we recognize the limitations to this study regar ding the findings drawn from the qualitative and subjective
collected data delivered by medical students and from
expertise of trainers. However, this survey, which may be
consi dered as an internal audit, suggests the need for
changes in the curriculum and for improvement of essential
logistic issues.
Key-words: medical undergraduation, post-graduation residency, continuing medical education, skills teaching-learning, simulation centre, technical procedures

SIMULATION-BASED TRAINING is used in anesthesia in
a variety of ways, such as task trainers for intubation and
major vascular access, crisis resource management, transeso-
phageal echocardiography(TEE), and screen-based simulation.
The use of high-fidelity mannequin simulators in cardiac
anesthesia training is somewhat limited by their inability to
simulate the cardiopulmonary bypass(CPB) state.Thepro-
grammed physiology of the Human Patient Simulator(HPS,
Anesthesia Model CAE Healthcare, Sarasota, FL) does not allow
the combination of an adequate perfusion pressure in the presence of asystole or serious arrhythmias such as ventricular fibrillation, which may exist during CPB. In a previously described HPS-based simulation scenario for cardiac anesthesia, which included patient management during CPB, the authors report keeping the actual scenario in “pause” mode for the period of CPB during the scenario. An externa lpressure input from a pressurized bag was fed in to demonstrate the perfusion pressure of CPB. During this
period, common learning points related to management of the
patient on CPB were discussed.1
The present article reports the design of a mannequin-based
cardiac anesthesia simulation training(CAST) module to teach
patient management during CPB and discontinuation of CPB and the authors’  experience of using it in anesthesia resident training. Theadaptationsenabledthescenariotobemannequin-based
throughout without any break in the progression of the case,
maintaining a degree of realism and allowing for clinical
interventions. The modifications applied, the construction of the
scenario, and its successful implementation are described.

"Background: Emergency medicine and wilderness medicine are close by kind of technical skills, because of their infrequent use. Treatments often need intra venous access to start. Depending of patient clinical statement, care should be quick and safe. Intra-venous access is usual. But, now, intra-osseous access gains in popularity in case of difficult venous access. Does medical technician often choose it? How and why is it used?
Methods: This study offers to compare intra-venous access and intra-osseous access in wilderness conditions like canyoning or caving by in-situ simulation. Users should answer to a questionnaire and give feedback about materials used by a Likert scale. 13 medical doctors were questioned after rescue camp in Pyrenees Mountains.
Results: Even if the time to success in the two accesses is the same, intra-osseous access seems to be quicker, easier and safer according to the users in case of emergency.
Conclusion: In-situ simulation is a good tool to test new materials or new care organization in real conditions. It is high fidelity simulation in healthcare.

Introduction : La médecine d’urgence et la médecine en milieu périlleux se ressemblent par leurs difficultés de réalisation de certains gestes techniques, étant donné leur rareté ou bien leurs conditions de réalisation. La prise en charge d’une victime nécessite souvent la pose d’une voie veineuse afin de pouvoir entreprendre une thérapeutique. Suivant l’état clinique du patient ou bien en fonction du milieu dans lequel est arrivé l’accident, il faut agir rapidement et sûrement. La voie intra-osseuse est une alternative à la voie veineuse périphérique dite classique dans ces situations particulières. Mais est-elle souvent choisie ? Quelle est la performance des soignants lors de sa pose ? Quel est le ressenti des utilisateurs ?
Méthode : Cette étude propose à des sauveteurs en milieu périlleux de comparer, dans un environnement hostile comme la spéléologie ou le canyoning, la pose d’une voie intra-osseuse avec une voie veineuse périphérique sur simulateur. Ils doivent exprimer leur ressenti par rapport aux deux méthodes sur une échelle de Likert. Treize médecins en stage de médecine de montagne dans les Pyrénées françaises ont répondu au questionnaire.
Résultats : Il semble que la pose de la voie intra-osseuse est réalisée dans les mêmes délais que la voie veineuse périphérique mais que la voie intra-osseuse est ressentie plus rapide, plus facile et plus sûre et elle serait préférée en cas d’urgence en milieu périlleux.
Conclusion : La simulation in situ, en dehors des laboratoires, sur les lieux même d’exercice des professionnels de santé est un outil formidable pour tester l’organisation des soins ou une nouvelle technique, tout en évoluant dans un contexte d’apprentissage haute fidélité."

Abstract: This qualitative study focuses on how knowings and learning take place in full-scale simulation training of medical and nursing students, by drawing upon actor-network theory (ANT). ANT situates materiality as a part of the social practic- es. Knowing and learning, according to ANT, are not simply cognitive or social phenomena, but are seen as emerging as effects of the relation between material assemblages and human actors being performed into being in particular locations. Data consists of observations of simulations performed by ten groups of students. The analysis focuses on the emerging knowings in the socio-material— arrangements of three locations involved in the simulation—the simulation room, the observation room and the reflection room. The findings indicate that medical knowing, affective knowing and communicative knowing are produced in different ways in the different locations and material arrangements of the simulation cycle.

The secularization of the modern fields of knowledge has lead to deprivation of religious and spiritual considerations, particularly in the current medical curriculum. In the past, the heavy medical curriculum has been blamed as a major contributing factor of production of ‘disease-oriented’ rather than ‘patient-oriented’ medical practitioners. Undergraduate students are very much unprepared to integrate the Islamic knowledge acquired during school-going years into the hectic life and specific conditions that they will encounter in the real clinical settings. There is a great need to reform the current education system to produce critical-minded medical practitioners, especially from the various aspects of the Islamic perspective. In IIUM, the teaching of medicine is augmented by series of relevant lectures and programs in line with the University’s Islamization of Human Knowledge agenda. The Department of Orthopaedics, Traumatology and Rehabilitation of IIUM has taken a step ahead ...

Transgender people report high rates of discrimination and substandard care in many health care settings. This is attributed to a lack of provider training about, experience with, and knowledge of the needs of transgender patients. To address this, we developed a simulation experience for primary care residents to interact with transgender patients and learn to address their unique health needs.

The secularisation of the modern fields of knowledge leads to the deprivation of religious and spiritual considerations, particularly in the current medical curriculum. In the past, the heavy medical curriculum has been blamed as a major contributing factor of production of ―disease- oriented‖ rather than ―patient-oriented‖ medical practitioners. Undergraduate students are very much unprepared to integrate the Islamic knowledge acquired during school-going years into the hectic life and specific conditions that they will encounter in the real clinical settings. There is a great need to reform the current education system to produce critical-minded medical practitioners, especially from the various aspects of the Islamic perspective. In IIUM, the teaching of medicine is augmented by series of relevant lectures and programs in line with the University‖s Islamization of Human Knowledge agenda. The Department of Orthopaedics, Traumatology and Rehabilitation of IIUM has taken a step ahead by introducing the Islamic Input in Orthopaedics (Triple IO) Module since 2002. Since its implementation, various obstacles have been faced and many improvements have been made. After more than a decade, we would like to share our experience in conducting the program and how to improve it further to cope with future challenges.

Her bireyin gereksinimlerinin saptanması
ve bu gereksinimlerin kendi ülkesinde mevcut olan
en iyi araç- gereç ve yöntemlerle karşılanmasını
isteme hakkı vardır
Stomaterapinin Temel Amacı
Yara, ostomi ve inkontinens problemi olan bireyin
problemlerini çözmek
Bireyi sorunları ile baş edebilecek yeterliliğe getirmek
Bireyin üretken, kaliteli bir yaşam sürdürmesini sağlamaktır

Stoma ameliyatı geçirip sonrasında stomalı hayata alışmak kolay değildir. Doğru hazırlık, doğru tavsiye, doğru ürünler ve destek bu konuda yardımcı olabilir. Stoma bakımında standartları belirleyen ostomi ürünleri ve aksesuarları üretebilmemizi ve böylece dünya çapında ostomili bireylerin hayatlarını en iyi şekilde yaşayabilmelerine yardımcı olmamızı sağlar.

Stoma nedir?
Stomanın tam olarak ne olduğunu ve nasıl oluştuğunu anlamak, bunun günlük hayatınızı nasıl etkileyebileceği konusundaki kontrolü ele almanızda ilk önemli adımdır.
Stomanın ne olduğunu anlamak

Neden ostomi torbası kullanmam gerekiyor?

Neden ostomi torbası kullanmam gerekiyor?
Stomanızdan gelen çıkışı güvenli ve uygun şekilde toplamak için bir ostomi torbasının kullanılması gerekir.

Stomanız günlük hayatınızı nasıl etkileyebilir?

Stoma ile yaşamaya alışmanız zaman alacaktır. Ancak bunun spordan sosyal hayata kadar eskiden yaptığınız şeyleri yapmanızı engellemesi için bir neden yoktur.

The study aims to understand what makes a 'successful simulation', one that follows the planned sequence of events embedded in the simulated scenario, thus producing the intended learning path and learning outcomes for the participating students. The study is based on observations of 15 full-scale simulation sessions of acute trauma handling during inter-professional training of medical and nursing students. The study shows that the briefing preceding the simulation frames the students' emergent actions during the scenario by demarcating 'possibilities' and 'impossibilities' for actions during the exercise. This in turn defines what actions are 'appropriate' and 'inappropriate' when the scenario is enacted. The simulation exercises are emergent and co-constituted by the diverse participating, socio-material actors. The extent to which this socio-material assemblage manages to produce and maintain the enactment of the patient during the simulation signifies the success or failure of the intended learning path of the exercise. Biographical notes: Song-ee Ahn is a Senior Lecturer at the Department of Behavioural Sciences and Learning, Linköping University in Sweden. Her research interests focus on socio-materialities and educational practices in higher education, such as inter-professional learning, simulation-based medical education and international education.

TR
Amaç: Ankara Üniversitesi Tıp Fakültesi Dönem-3 öğrencilerine yönelik olarak geliștirilen ve 2004’den beri
sürdürülmekte olan “Uygulamalı Aydınlatılmıș Onam Alma Becerisi (UAOAB)” eğitim programı yıllar içinde
özellikle 2012 yılı sonrasında olmak üzere bazı yapısal değișikliklere uğramıștır. Bu çalıșma, öğrencilerin
program hakkındaki düșüncelerinin, bu değișikliklere paralel olarak zaman içinde farklılık gösterip göstermediğini
ortaya koymak amacıyla tasarlanmıștır.
Gereç ve Yöntem: 2010-14 yılları arasında UAOAB eğitimi kapsamında gerçekleștirilen uygulama oturumlarına
katılan öğrencilerden, ilgili eğitim çalıșmasına ilișkin bir değerlendirme anketi doldurmaları istenmiștir.
Elde edilen veriler istatistiksel olarak analiz edilmiș ve ulașılan bulgular yorumlanmıștır.
Bulgular: Öğrencilerin büyük bölümü “aydınlatılmıș onam” konusunu mesleki yașamları açısından önemli
bulmakta ancak konu ile ilgili bilgi ve becerilerinin yeterli olmadığını düșünmektedir. Öğrenciler, genel
olarak UAOAB eğitiminden memnundurlar (ort. %81,3). Programın mesleki sorumluluk kazandırma ve iletișim
becerilerinin öğretilmesi açısından etkili olduğunu düșünen öğrencilerin oranı 2012-14 yılları arasında
önceki yıllara göre anlamlı olarak daha fazladır.
Sonuç: Öğrenciler, “aydınlatılmıș onam” ve ilgili konular hakkında bilgi ve beceri kazanmaya gereksinim
duymaktadırlar. Öğrencilerin UAOAB eğitim programı hakkındaki olumlu kanılara sahip olması, programın
geliștirilerek sürdürülmesi yönündeki çabaları destekleyici bir bulgudur. Zaman içindeki değișimi gösteren
sonuçlar, standardize hastalar ve simülasyon tekniklerinin etkin kullanımının programı daha etkili kıldığını
düșündürmektedir.

ENG
Aim: Applied education program on “Obtaining Informed Consent Skill (UAOAB)”, which was developed for
Ankara University Faculty of Medicine Grade-3 students and has been continuing since 2004, underwent
some structural changes over the years especially after 2012. This study was designed to reveal whether
students’ thoughts on the program differ parallel to these changes through time.
Material and Method: Students who attended practice sessions as a part of the UAOAB education between
the years of 2010-14 were asked to fill out an evaluation questionnaire about this education study. The data
collected were statistically analyzed and findings were interpreted.
Findings: The great majority of the students consider “informed consent” an important issue with respect to
their professional lives; however, they think that their knowledge and skills are insufficient. They are generally
satisfied with the UAOAB education (mean 81.3%). The ratio of students, who think that the program is
efficient in terms of professional responsibility acquisition and teaching communication skills, is significantly
higher between the years of 2012-14 than previous years.
Results: Students are in need of acquiring knowledge and skills about “informed consent” and related issues.
The finding that students have positive opinions regarding UAOAB education program supports endeavors
to continue the program by developing it progressively. Results showing the change over time
suggest that the use of standardized patients and simulation techniques lead to a more efficient program.

Practitioners will face acute illness episodes in a plethora of conditions, and simulation technologists have traditionally aimed to model these environments in order to facilitate experiential learning. Actual cars have been demolished for roadside accident simulations; Human Patient Simulators are left in woodland areas with amputations; and simulated wards and theatres are created with working beds and ventilators for in-hospital emergency management. Yet, with all the advancements in healthcare simulation technology, there still remains a lack of simulated environments for the community setting, even though their utility has been proven (Distelhorst and Wyss, 2013; Yeager and Gotwals, e129-e156, 2009). With the future drive toward more home based clinical treatment due to the rising cost of acute care and cuts to the National Health Service, clinicians should be prepared to confront health crisis as it occurs in patient’s homes. Here, the authors discuss the creation of a Daily Living Simulation Suite for pre-registration Allied Health and Nursing education. The need for simulated home environments, practical considerations for implementation and model simulations through video discussion will be presented in order to conceptualise the approach. The suite is still a work in progress, and discussions around optimisation for individual curriculums will be discussed.

Working with organs and extracted tissue blocks is an essential task in many medical surgery and anatomy environments. In order to prepare specimens from human donors for further analysis, wet-bench workers must properly dissect human tissue and collect metadata for downstream analysis, including information about the spatial origin of tissue. The Registration User Interface (RUI) was developed to allow stakeholders in the Human Biomolecular Atlas Program (HuBMAP) to register tissue blocks-i.e., to record the size, position, and orientation of human tissue data with regard to reference organs. The RUI has been used by tissue mapping centers across the HuBMAP consortium to register a total of 45 kidney, spleen, and colon tissue blocks, with planned support for 17 organs in the near future. In this paper, we compare three setups for registering one 3D tissue block object to another 3D reference organ (target) object. The first setup is a 2D Desktop implementation featuring a traditional screen, mouse, and keyboard interface. The remaining setups are both virtual reality (VR) versions of the RUI: VR Tabletop, where users sit at a physical desk which is replicated in virtual space; VR Standup, where users stand upright while performing their tasks. All three setups were implemented using the Unity game engine. We then ran a user study for these three setups involving 42 human subjects completing 14 increasingly difficult and then 30 identical tasks in sequence and reporting position accuracy, rotation accuracy, completion time, and satisfaction. All study materials were made available in support of future study replication, alongside videos documenting our setups. We found that while VR Tabletop and VR Standup users are about three times as fast and about a third more accurate in terms of rotation than 2D Desktop users (for the sequence of 30 identical tasks), there are no significant differences between the three setups for position accuracy when normalized by the height of the virtual kidney across setups. When extrapolating from the 2D Desktop setup with a 113-mm-tall kidney, the absolute performance values for the 2D Desktop version (22.6 seconds per task, 5.88 degrees rotation, and 1.32 mm position accuracy after 8.3 tasks in the series of 30 identical tasks) confirm that the 2D Desktop interface is well-suited for allowing users in HuBMAP to register tissue blocks at a speed

Introduction
Creativity and improvisation are recognized as important aspects of training expertise in domains such as business and the arts, yet rarely discussed in medical education. This article examines how creativity and improvisation play out in the ways teachers give ‘expressive instructions’ to medical students when teaching physical skills.

Methods
Ethnographic fieldwork was conducted in a medical school in Maastricht, the Netherlands, with first, second and third year students learning physical examination skills. Over 230 h of fieldwork was conducted in the Skills Lab, including 34 tutorials of 1.5 h duration, with 11 different teachers and over 500 students. Patterns found in the fieldnotes were thematically analyzed using an inductive approach, drawing on sociological theories of craftsmanship.

Results
Findings showed that teachers improvise beyond the standardized lesson structure and classroom set-up, giving what we call, drawing on sociological theory, ‘expressive instructions’. This was visible in two main ways: 1) by teachers using their own bodies; 2) by teachers using materials that came to hand.

Discussion
This research highlights the important yet underexplored role of creativity and improvisation in teaching physical skills. Creativity and improvisation appear to be particularly important when training expertise in skills that are difficult to articulate and thus require expressive instructions, due for example to their sensory nature. Focusing on how expressive instructions play out in medical education offers insights into the tacit components of expertise development, a process which builds upon a long period of teachers’ skilled practice.

One-lung ventilation (OLV) can be accomplished by using ether a double-lumen endotracheal tube (DLT) or a bronchial blocker. Patient factors, surgical requirements and the anesthesiologist’s expertise influence technique choice. Bronchial blockers are in general less traumatic, safer to place, and suitable in a wider variety of scenarios than DLTs, but require greater technical skill. We designed a study to determine whether trainees can achieve OLV using a bronchial blocker on completion of a 4-week multimodal training module. Article can be found at http://www.seahq.net/images/media/jepm/XIX/VolXIX_Issue2_Foley.pdf

KEY MESSAGES
• Although simulation is often considered to provide a safe environment for experiential learning without risking harm to ‘patients’, we are aware that learners, and those directly involved in the learning process, are at potential risk too.
• Facilitators of simulation-based education need to continue to advance ethical frameworks around such learning.
• Such ethical frameworks should guide best practice in how risks are minimized for those who learn and benefit from such teaching practices.
• In terms of virtue ethics, simulation-based education can contribute to the development of a student into a professional.
• If the process of debriefing and reflection becomes merely a performative technique, simulation-based education may fail to be as beneficial for students in generating self knowledge, and consciously realizing the process of their professional development.