TY - JOUR
AU1 - Polk, Travis M
AU2 - Greer, Joy
AU3 - Alex, John
AU4 - Kiser, Rebecca
AU5 - Gunzelman, Kim
AU6 - Petersen, Carl
AU7 - Spooner, Michael
AB - Abstract Background Fifty percent of graduating U.S. Navy post-graduate year (PGY)-1 physicians will practice in the operational environment before returning to residency training. However, current internship structure is less rotational and focuses more on specialty-specific training. Therefore, these physicians may not be fully prepared for this primary care role. Methods Based on the U.S. Navy privileges for General Medical Officers, a comprehensive didactic and simulation curriculum was developed. Twenty-three procedural skill competencies (SK) and five validated standardized patient (SP) scenarios were identified. During the SK portion, learners reviewed instructional videos, read reference materials, and practiced with partial task trainers before small-group sessions with subject matter experts (SME). Separate SP round-robin sessions were conducted and feedback provided by SMEs and SPs. Learners demonstrated competency or were remediated. Results One hundred and three PGY-1 trainees participated over 2 yr. All trainees met requirements during the SK phase. During the SP phase, seven learners required remediation. All learners ultimately met requirements for privileging. Conclusion The Simulation Training for Operational Medicine Providers curriculum for future General Medical Officers is an effective tool for primary care skill training and credentialing. Plans for export to other Graduate Medical Education sites are underway and further evaluation of skills retention is warranted. Introduction Military medicine faces many challenges in providing both in garrison care and deployed medical support. Operational physicians must be able to provide not only essential primary care but also initial trauma stabilization and care in the most remote and austere settings. Additionally, several military populations require unique considerations including aviation, undersea/diving, nuclear power, and special operations.1 Traditionally, the additional training provided to these physicians has focused on military-specific and combat casualty needs with the assumption that all are capable of the necessary primary care tasks. Yet, this assumption may be inadequate when considering the evolution of undergraduate and graduate medical education. In recognition of this dichotomy, there have been multiple recent efforts to decrease reliance on the general medical officer (GMO) across the Department of Defense. The U.S. Army now utilizes very few GMOs, but instead uses the Professional Filling System, or PROFIS, to fill operational billets when required. However, many billets are filled by rank, rather than specialty; therefore, many of these physicians may also have varying levels of competency in primary care. On the other hand, although the U.S. Navy has sought to increase the number of fully trained family medicine, internal medicine, and emergency medicine physicians assigned to the operational community, a complete conversion of these billets has not been feasible due to the quantity of physicians required to meet the demands of the Navy and Marine Corps. Thus, additional training in primary care skills may be necessary to prepare these young officers for their GMO assignments. Up to 50% of U.S. Navy physicians in training will complete tours providing primary care to operational forces following their first post-graduate year (PGY-1). These young military medical officers function as general practitioners in the operational environment while serving tours as general medical officers, flight surgeons, and undersea/diving medical officers. This service usually means a training hiatus of at least 2–3 yr following internship before returning to residency training. Historically, military PGY-1 internships were designed to be “rotational” in nature and exposed the trainee to a broad set of specialties in preparation for this military requirement. However, there has been an increasing shift to specialty-specific categorical internships over the past 15 yr driven by increased subspecialty training demands from the American Council on Graduate Medical Education (ACGME), residency work-hour restrictions, and other patient safety priorities. Due to these changes in the structure of the PGY-1 yr, interns now graduate with varying degrees of preparedness for service as an operational medical officer depending upon their internship specialty. Thus, a training gap now exists and many residency program directors have become reluctant to attest to the competency of their trainees in knowledge and skills outside of their given specialty. Additionally, a similar need may exist for subspecialized physicians filling senior operational medical billets and returning to operational primary care practice after years of specialty-specific assignments. In response to these perceived training gaps, we developed a comprehensive simulation-based curriculum to facilitate the privileging needs for the fleet. The Simulation Training for Operational Medical Providers (STOMP) program has developed into a three-phase curriculum that incorporates skill-based teaching and assessment, use of standardized patients for clinical assessment, and a capstone operational medicine seminar. As this program enters its third year of implementation and expands to multiple sites, a systemic program evaluation is needed to assess the curriculum, guide necessary course updates, and facilitate strategic planning. Through this process, we sought to determine whether this course is meeting the objective of preparing graduating PGY-1 trainees for their assignments in operational primary care. Methods Training Gap Analysis The current General Medical Officer (GMO) privileges were obtained from the Tri-Service Master Privileging List available online through the Defense Health Agency’s Centralized Credentialing Quality Assurance System2 (see Appendix 1 for GMO privileges). The privilege list (27 core and 12 non-core) was analyzed to determine the extent of the training gap and input was sought from the Graduate Medical Education Committee, Intern Advisory Committee, and other subject matter experts (SME) regarding which privileges were adequately addressed in each specialty’s internship program. Following synthesis of these findings, 23 procedural skills and five specialty areas of focus for knowledge-based assessment were identified as potential course requirements. Curriculum Design Once course requirements were determined, the curriculum development process began. A core team of simulation educators, simulation center technicians, and SMEs was assembled. Twenty-three procedural skill competencies (SK) and five validated standardized patient (SP) scenarios were developed for inclusion. The skill competencies were divided among eight specialty stations: emergency medicine, dermatology, podiatry, general surgery, ophthalmology, otolaryngology, gynecology, and orthopedics. Before attending SK small-group sessions with a specialty-specific SME, trainees were asked to preview videos corresponding to each skill (ClinicalKey, Elsevier, https://www.clinicalkey.com) and to practice the skills on task trainers that were made available 24/7 in the resident office space. During the SK session, learners received instruction from an appropriate SME and demonstrated the skill on a partial task trainer. Table I lists the skills and competencies covered. Table I. Simulation Training for Operational Medicine Providers Course Competencies (Clinical and Procedural Skills) Competency . Specialty . Standardized patient  Abdominal pain General surgery  Headache Neurology  Low back pain-compression fracture/knee pain Orthopedics  Syncope/chest pain Cardiology  Panic disorder Psychiatry Procedural skills  Punch biopsy Dermatology  Shave biopsy Dermatology  Excisional biopsy Dermatology  Cryosurgical removal of skin lesion Dermatology  Topical treatment of skin lesion Dermatology  Electrocardiogram interpretation Cardiology  Laceration repair (simple/complex) Emergency medicine  Topical/local infiltration of anesthetic Emergency medicine  Tympanometry ENT  Removal of nasal foreign body ENT  Removal of otic foreign body ENT  Incision and drainage of cyst/abscess General surgery  Incision and drainage of thrombosed hemorrhoid General surgery  Pap smear Gynecology  Removal of intrauterine device Gynecology  Slit lamp examination Ophthalmology  Removal of corneal foreign body Ophthalmology  Tonometry Ophthalmology  Splint/immobilize extremities Orthopedics  Reduction of simple fractures/dislocations Orthopedics  Peripheral nerve block anesthesia Podiatry  Complete/partial nail removal (with or without nail matrix destruction) Podiatry Competency . Specialty . Standardized patient  Abdominal pain General surgery  Headache Neurology  Low back pain-compression fracture/knee pain Orthopedics  Syncope/chest pain Cardiology  Panic disorder Psychiatry Procedural skills  Punch biopsy Dermatology  Shave biopsy Dermatology  Excisional biopsy Dermatology  Cryosurgical removal of skin lesion Dermatology  Topical treatment of skin lesion Dermatology  Electrocardiogram interpretation Cardiology  Laceration repair (simple/complex) Emergency medicine  Topical/local infiltration of anesthetic Emergency medicine  Tympanometry ENT  Removal of nasal foreign body ENT  Removal of otic foreign body ENT  Incision and drainage of cyst/abscess General surgery  Incision and drainage of thrombosed hemorrhoid General surgery  Pap smear Gynecology  Removal of intrauterine device Gynecology  Slit lamp examination Ophthalmology  Removal of corneal foreign body Ophthalmology  Tonometry Ophthalmology  Splint/immobilize extremities Orthopedics  Reduction of simple fractures/dislocations Orthopedics  Peripheral nerve block anesthesia Podiatry  Complete/partial nail removal (with or without nail matrix destruction) Podiatry ENT, ear, nose, and throat Open in new tab Table I. Simulation Training for Operational Medicine Providers Course Competencies (Clinical and Procedural Skills) Competency . Specialty . Standardized patient  Abdominal pain General surgery  Headache Neurology  Low back pain-compression fracture/knee pain Orthopedics  Syncope/chest pain Cardiology  Panic disorder Psychiatry Procedural skills  Punch biopsy Dermatology  Shave biopsy Dermatology  Excisional biopsy Dermatology  Cryosurgical removal of skin lesion Dermatology  Topical treatment of skin lesion Dermatology  Electrocardiogram interpretation Cardiology  Laceration repair (simple/complex) Emergency medicine  Topical/local infiltration of anesthetic Emergency medicine  Tympanometry ENT  Removal of nasal foreign body ENT  Removal of otic foreign body ENT  Incision and drainage of cyst/abscess General surgery  Incision and drainage of thrombosed hemorrhoid General surgery  Pap smear Gynecology  Removal of intrauterine device Gynecology  Slit lamp examination Ophthalmology  Removal of corneal foreign body Ophthalmology  Tonometry Ophthalmology  Splint/immobilize extremities Orthopedics  Reduction of simple fractures/dislocations Orthopedics  Peripheral nerve block anesthesia Podiatry  Complete/partial nail removal (with or without nail matrix destruction) Podiatry Competency . Specialty . Standardized patient  Abdominal pain General surgery  Headache Neurology  Low back pain-compression fracture/knee pain Orthopedics  Syncope/chest pain Cardiology  Panic disorder Psychiatry Procedural skills  Punch biopsy Dermatology  Shave biopsy Dermatology  Excisional biopsy Dermatology  Cryosurgical removal of skin lesion Dermatology  Topical treatment of skin lesion Dermatology  Electrocardiogram interpretation Cardiology  Laceration repair (simple/complex) Emergency medicine  Topical/local infiltration of anesthetic Emergency medicine  Tympanometry ENT  Removal of nasal foreign body ENT  Removal of otic foreign body ENT  Incision and drainage of cyst/abscess General surgery  Incision and drainage of thrombosed hemorrhoid General surgery  Pap smear Gynecology  Removal of intrauterine device Gynecology  Slit lamp examination Ophthalmology  Removal of corneal foreign body Ophthalmology  Tonometry Ophthalmology  Splint/immobilize extremities Orthopedics  Reduction of simple fractures/dislocations Orthopedics  Peripheral nerve block anesthesia Podiatry  Complete/partial nail removal (with or without nail matrix destruction) Podiatry ENT, ear, nose, and throat Open in new tab Appropriate partial task trainers were identified for each skill. If an appropriate simulation device was not commercially available, partial task trainers were modified or novel training aids developed. Several task trainers required development or modification for this curriculum and two novel partial task trainers were developed for this course. A thrombosed hemorrhoid model was developed utilizing a rectal exam trainer, balloons, foam, and other standard simulation consumables. Likewise, a corneal foreign body model was developed using a gelatin technique and glitter. Finally, as an example of necessary modifications, a head trauma trainer (Mr. Hurt, Laerdal Medical, Wappingers Falls, NY, USA) was modified to allow nasal and otic foreign body retrieval. Figure 1 illustrates several of these partial task trainers in use. Figure 1. Open in new tabDownload slide Representative partial task trainer set-up. (A) Nail bed and peripheral anesthesia model; (B) novel thrombosed hemorrhoid model; (C) novel corneal foreign body model; (D) modified nasal and otic foreign body model. Figure 1. Open in new tabDownload slide Representative partial task trainer set-up. (A) Nail bed and peripheral anesthesia model; (B) novel thrombosed hemorrhoid model; (C) novel corneal foreign body model; (D) modified nasal and otic foreign body model. Five previously validated standardized patient (SP) scenarios were selected. This Objective Structured Clinical Exam (OSCE) included scenarios in Neurology, Cardiology, General Surgery, Orthopedics, and Psychiatry. In the second year of the program, the environment and background set for these scenarios was further modified to better reflect the operational environment. Our SPs were local active duty, enlisted sailors who have volunteered their time and all have completed a formal training course offered by our simulation center at least annually in conjunction with Eastern Virginia Medical School. In the second year of the program, a capstone operational medicine symposium was added to the curriculum. This seminar focused on the pearls and pitfalls for a GMO in the deployed setting. This popular session included common diagnoses, patient safety concerns, emergencies, and key resources in the high-yield areas of orthopedics, psychiatry, and dermatology. Individual and Course Evaluation The overall objective of the course was to insure adequate exposure to the required primary care and operational skills in the General Medical Officer privilege list. The curriculum was specifically designed as a formative assessment process. To assure that learners received quality instruction, feedback, and remediation, all proctors were attending-level, specialty-specific SMEs. During the SK phase, students received immediate instruction, feedback, and remediation of performance deficits by these specialty-specific SMEs for each skill. The opportunity for deliberate practice was given before and during the session. Learners either demonstrated competency or were remediated individually until proficient in the same session. In the second year, pre- and post-course skills confidence surveys were also administered. In the SP phase, both SME proctors and SPs completed standardized assessment tools following completion of each patient scenario. Learners received an overall determination of pass or remediate for each scenario from SME evaluators, as well as more specific ratings for history, physical examination, communication, judgment, and clinical organization. SPs provided feedback with regard to questioning technique, communication, empathy, and shared plan. When possible, students were remediated on the spot for minor deficiencies through the process of Socratic discussion. If the SME felt that there were significant deficiencies that could not be immediately remediated, a different OSCE scenario in that specialty was scheduled for the learner at a future date. Debriefing was performed immediately following each scenario by both SME and SP with an additional broader focused group debriefing following completion of all scenarios. Students were given the opportunity to evaluate the course with post-course surveys after each phase. Results One hundred and three PGY-1 trainees participated in the program over two academic years from 2015 to 2016 (49 and 54 learners, respectively). All interns proceeding to operational assignments following graduation participated in the program. Intern specialty tracks included surgery, internal medicine, obstetrics and gynecology, otorhinolaryngology, orthopedics, psychiatry, pediatrics, and transitional year. During the SK phase, all trainees met proficiency requirements by the end of each session without need for additional scheduled remediation. During the second year of implementation, we also assessed self-rated procedural confidence before and after participation in the program. Figure 2 shows a summary of these results and notes an overall improvement in skills confidence across all specialties for physicians participating in the course. Trainees had significant improvement in self-rated confidence in primary care procedures and their ability to manage common primary care patient complaints. Figure 2. Open in new tabDownload slide Self-rated procedural confidence measuring before and 1 wk after procedural skills competencies phase of Simulation Training for Operational Medicine Providers program. Ear, nose, and throat (ENT), dermatologist (DERM), effective dose (ED), surgical (SURG), gynocology (GYN), ophthalmologist (OPHTHO), and orthodontist (ORTHO). Figure 2. Open in new tabDownload slide Self-rated procedural confidence measuring before and 1 wk after procedural skills competencies phase of Simulation Training for Operational Medicine Providers program. Ear, nose, and throat (ENT), dermatologist (DERM), effective dose (ED), surgical (SURG), gynocology (GYN), ophthalmologist (OPHTHO), and orthodontist (ORTHO). During the SP phase, each participant completed five SP scenarios in different specialty focus areas. A total of 13 individual SP scenario events required remediation representing 3% of the total OSCEs administered and 13% of the learners. Remediated SP scenario events were evenly distributed across the five evaluated specialties. Ultimately, all participants successfully completed the scenarios from each required specialty area. Specific areas of weakness were the performance of focused abdominal exam (18%, n = 18), psychiatric history/mental status exam (15%, n = 15), and focused neurological exams (28%, n = 29). All other categories assessed by SMEs had less than 10% of trainees with borderline or deficient scores. Figure 3 summarizes the SP’s assessment of participants’ communication weaknesses noted during these scenarios. Overall, post-course surveys were positive with participants reporting that all aspects of the program were beneficial. Figure 3. Open in new tabDownload slide Provider communication deficiencies (as assessed by standardized patients [SP]). Figure 3. Open in new tabDownload slide Provider communication deficiencies (as assessed by standardized patients [SP]). The annual cost to train 50 trainees was $22,990 excluding fixed personnel or facilities costs. As we utilized volunteer active duty sailors for our SP pool, we had no associated costs for this personnel asset; however, we estimate that the cost to hire SPs for this phase would be approximately $7500. Therefore, the estimated cost for each trainee to complete the program is approximately $610. Table II lists the key partial task trainers and consumables along with respective cost. Table II. Commercial Trainers and Consumable Supplies Used Specialty . Procedure . Simulation Equipment . Cost . Consumables . Cost . Total . Dermatology Punch, shave, and excisional biopsy Limbs and things lesions pad $42 × 75 = $3150 Needles, syringes, scalpels, punches, vials of normal saline $500 $3650 Emergency medicine Repair of cutaneous lacerations and topical/local infiltration Limbs and things wound closure pad $45 × 75 = $3,375 Needles, syringes, scalpels, vials of normal saline, suture $250 $3625 ENT Removal of nasal foreign body Laerdal Mr Hurt Head $1410 N/A — $1410 ENT Removal of otic foreign body Limbs and things ear examination simulator II $2900 N/A — $2900 General surgery I&D of cysts/abscesses Limbs and things or SurgiRealSebaceous cyst pad $59 × 75 = $4425 Needles, syringes, scalpels, vials of normal saline $375 $4800 General surgery Excision thrombosed hemorrhoid Limbs and things rectal exam $1835 Needles, syringe, curved scissors, scalpel. Hemorrhoid: small purple balloon, foam, corn syrup, blue/red food coloring $75 $1910 OB/GYN Pap smear and IUD removal Zoe gynecologic simulator $595 Pap Smear Kits, IUD $500 $1095 Ophthalmology Removal of ocular foreign body Ocular foreign body model (custom) $50 Glitter, needles, cotton tip applicators $100 $150 Orthopedics Splint/immobilize extremities and reduction of closed fractures/dislocations N/A — Casting supplies/splints $1000 $1000 Podiatry Peripheral nerve block and complete/partial nail removal Limbs and things toe ends (pack of 3) $90 × 25 = $2250 Needles, syringes, vials of normal saline $200 $2450 Total for class of 50 students $22,990 Specialty . Procedure . Simulation Equipment . Cost . Consumables . Cost . Total . Dermatology Punch, shave, and excisional biopsy Limbs and things lesions pad $42 × 75 = $3150 Needles, syringes, scalpels, punches, vials of normal saline $500 $3650 Emergency medicine Repair of cutaneous lacerations and topical/local infiltration Limbs and things wound closure pad $45 × 75 = $3,375 Needles, syringes, scalpels, vials of normal saline, suture $250 $3625 ENT Removal of nasal foreign body Laerdal Mr Hurt Head $1410 N/A — $1410 ENT Removal of otic foreign body Limbs and things ear examination simulator II $2900 N/A — $2900 General surgery I&D of cysts/abscesses Limbs and things or SurgiRealSebaceous cyst pad $59 × 75 = $4425 Needles, syringes, scalpels, vials of normal saline $375 $4800 General surgery Excision thrombosed hemorrhoid Limbs and things rectal exam $1835 Needles, syringe, curved scissors, scalpel. Hemorrhoid: small purple balloon, foam, corn syrup, blue/red food coloring $75 $1910 OB/GYN Pap smear and IUD removal Zoe gynecologic simulator $595 Pap Smear Kits, IUD $500 $1095 Ophthalmology Removal of ocular foreign body Ocular foreign body model (custom) $50 Glitter, needles, cotton tip applicators $100 $150 Orthopedics Splint/immobilize extremities and reduction of closed fractures/dislocations N/A — Casting supplies/splints $1000 $1000 Podiatry Peripheral nerve block and complete/partial nail removal Limbs and things toe ends (pack of 3) $90 × 25 = $2250 Needles, syringes, vials of normal saline $200 $2450 Total for class of 50 students $22,990 Open in new tab Table II. Commercial Trainers and Consumable Supplies Used Specialty . Procedure . Simulation Equipment . Cost . Consumables . Cost . Total . Dermatology Punch, shave, and excisional biopsy Limbs and things lesions pad $42 × 75 = $3150 Needles, syringes, scalpels, punches, vials of normal saline $500 $3650 Emergency medicine Repair of cutaneous lacerations and topical/local infiltration Limbs and things wound closure pad $45 × 75 = $3,375 Needles, syringes, scalpels, vials of normal saline, suture $250 $3625 ENT Removal of nasal foreign body Laerdal Mr Hurt Head $1410 N/A — $1410 ENT Removal of otic foreign body Limbs and things ear examination simulator II $2900 N/A — $2900 General surgery I&D of cysts/abscesses Limbs and things or SurgiRealSebaceous cyst pad $59 × 75 = $4425 Needles, syringes, scalpels, vials of normal saline $375 $4800 General surgery Excision thrombosed hemorrhoid Limbs and things rectal exam $1835 Needles, syringe, curved scissors, scalpel. Hemorrhoid: small purple balloon, foam, corn syrup, blue/red food coloring $75 $1910 OB/GYN Pap smear and IUD removal Zoe gynecologic simulator $595 Pap Smear Kits, IUD $500 $1095 Ophthalmology Removal of ocular foreign body Ocular foreign body model (custom) $50 Glitter, needles, cotton tip applicators $100 $150 Orthopedics Splint/immobilize extremities and reduction of closed fractures/dislocations N/A — Casting supplies/splints $1000 $1000 Podiatry Peripheral nerve block and complete/partial nail removal Limbs and things toe ends (pack of 3) $90 × 25 = $2250 Needles, syringes, vials of normal saline $200 $2450 Total for class of 50 students $22,990 Specialty . Procedure . Simulation Equipment . Cost . Consumables . Cost . Total . Dermatology Punch, shave, and excisional biopsy Limbs and things lesions pad $42 × 75 = $3150 Needles, syringes, scalpels, punches, vials of normal saline $500 $3650 Emergency medicine Repair of cutaneous lacerations and topical/local infiltration Limbs and things wound closure pad $45 × 75 = $3,375 Needles, syringes, scalpels, vials of normal saline, suture $250 $3625 ENT Removal of nasal foreign body Laerdal Mr Hurt Head $1410 N/A — $1410 ENT Removal of otic foreign body Limbs and things ear examination simulator II $2900 N/A — $2900 General surgery I&D of cysts/abscesses Limbs and things or SurgiRealSebaceous cyst pad $59 × 75 = $4425 Needles, syringes, scalpels, vials of normal saline $375 $4800 General surgery Excision thrombosed hemorrhoid Limbs and things rectal exam $1835 Needles, syringe, curved scissors, scalpel. Hemorrhoid: small purple balloon, foam, corn syrup, blue/red food coloring $75 $1910 OB/GYN Pap smear and IUD removal Zoe gynecologic simulator $595 Pap Smear Kits, IUD $500 $1095 Ophthalmology Removal of ocular foreign body Ocular foreign body model (custom) $50 Glitter, needles, cotton tip applicators $100 $150 Orthopedics Splint/immobilize extremities and reduction of closed fractures/dislocations N/A — Casting supplies/splints $1000 $1000 Podiatry Peripheral nerve block and complete/partial nail removal Limbs and things toe ends (pack of 3) $90 × 25 = $2250 Needles, syringes, vials of normal saline $200 $2450 Total for class of 50 students $22,990 Open in new tab Discussion In response to a perceived training gap, we have successfully designed and implemented a three-part simulation and didactic curriculum to support the training and privileging of future GMOs in primary care skills. To meet this objective, we incorporated the use of standardized patients, commercially available task trainers, and two novel partial tasker trainers. We specifically chose to incorporate both clinical OSCE scenarios and procedural skills sessions into a “boot camp” style course so that there were ample opportunities for expert guidance, deliberate practice, feedback, and remediation. This curriculum also provided a means to assess military physicians’ primary care skills before credentialing them for an operational tour. Human patient simulation has become increasingly important in health care education over the past several years. It is now an integral part of undergraduate and graduate medical education and is now recognized as a critical component in both surgical and non-surgical skills acquisition. Additionally, it is utilized to assist in licensing, privileging, and maintenance of certification. Although it is less common to use simulation as a formal assessment tool, the incorporation of OSCEs and task trainers to establish competence or proficiency is not a novel concept.3 Simulation has been a substantial part of initial medical licensing exams for several years. Since 2004, the United States Medical Licensing Exam (USMLE) has incorporated the use of standardized patient scenarios during USLME Step 2 and computerized clinical simulations during USLME Step 3 as an essential tool in the summative assessment process.4 Additionally, numerous courses include components of simulation as part of their formative and/or summative assessment, including Basic Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Fundamentals of Laparoscopic Surgery, and Advanced Trauma Life Support. At least two specialties, Anesthesia and Interventional Cardiology, now include simulation as part of the Maintenance of Certification process.5,6 OSCEs performed with standardized patients are also useful to improve or evaluate a learner’s clinical skills. The USMLE Step 2 examination permits examiners to assess both the ability of new physicians to solve clinical problems and demonstrate understanding of and support for the patient.4 Additionally, the Royal College of Physicians and Surgeons of Canada now incorporates SPs into its OSCE for certification in internal medicine.7 Skills training has been increasingly used for both education and assessment. The success of the OSCE process has led to development of a skill-based assessment known as Objective Structured Assessment of Technical Skills (OSAT). The OSAT may involve assessment of skills on actual patients or through the use partial task trainers.8 Task trainers have been noted to be useful not only for the physical fidelity of the model but also for their psychological fidelity, or the process of rehearsal of the constituent steps of a given procedure.9 Although most of the skill training literature focuses on data from surgical procedures, some literature is now available for teaching and assessing primary care skills. Schill et al demonstrated that suturing and knot tying skills in surgical interns can be improved and sustained long term if training incorporates appropriate targeted feedback and remediation in a formative assessment process.10 Improved diagnostic accuracy in direct ophthalmoscopy11 and otolaryngology12 has been demonstrated. Issenberg et al showed the benefit of cardiology patient simulator to teach heart and lung physical examinations. Internal medicine residents who underwent simulation training scored higher on a written multiple-choice test and a clinical skill examination.13 Improvement in laparoscopy surgical skills through use of a virtual reality trainer has been successfully validated.14 In addition, obstetric simulators have helped decrease incidence of complications from shoulder dystocia as well as improve team-based communication skills in a multidisciplinary setting. Simulation “boot camp” style programs have shown success with novice and intermediate learners as a means to improve and assess competency in clinical scenarios and with procedural skills.15–25 Ortiz Figueroa et al showed that a 1-d intern trauma boot camp can improve significantly team communication and crew resource management skills but may not have the same effect in improving more specific orthopedic trauma skills, suggesting that more time may needed to technical skills.23 In contrast, Cohen et al demonstrated that a 3-d intern boot camp using simulation-based mastery learning with deliberate practice allowed all interns to achieve a minimum passing standing in both clinical and procedural skills.16 Importantly, this study demonstrated that self-confidence and prior experience do not necessarily predict OSCE performance, highlighting the need for mastery learning and deliberate practice to achieve competency. However, MacKensie and Berkowitz reported that family practitioners who completed skill workshops during residency were not more likely to perform these skills and suggested that the performance of many skills may correlate more with opportunity rather than competence and self-confidence in procedural ability.21 There is also evidence that simulation experiences can translate to clinical outcomes and be effectively used as a credentialing tool. Implementation of resident training and credentialing curricula for the placement of central venous catheters has shown decreased catheter-related blood stream infections and other complications.26,27 Mentored simulation training in the cardiac catheterization laboratory has also translated into improved procedural skills.28 The ongoing linkage of clinical outcome and patient safety data to simulation experiences is a key to the long-term success of these costly endeavors. This study has several imitations. First, despite attempts to provide objective assessment of the learners, a substantial component of the assessment is reliant on the subjective interpretation of faculty SMEs and SPs. Additionally, our self-confidence data are both self-reported and lacks a prolonged time interval following course completion for skills degradation. Due to the immediate worldwide geographic dispersal of our learners following graduation, further determination of skill retention and course utility to operational medical care remains difficult. However, the limited data and feedback obtained have been positive and has successfully facilitated course refinement and strategic planning. Future course plans include determination of clinical skills retention and utility of skills in operation assignments via survey and skill retesting. Additionally, we are exploring the utility this curriculum as refresher training for more senior physicians returning to operational medicine across the Department of Defense. We also believe that similar course offerings could be useful for physicians in the rural or global health settings. Conclusion The STOMP course provides critical training and validation of primary care clinical and procedural skill for graduating PGY-1 physicians through the use of medical simulation. This curriculum directly supports the contemporary needs of Graduate Medical Education (GME) program directors and operational privileging authorities. Although this study represents only a single institution’s experience, the course has already been exported to other U.S. Navy GME sites and there is an ongoing discussion regarding Navy-wide implementation. Conflicts of Interest The authors have no conflicts of interest to disclose. Supplementary Data Supplementary data are available at Military Medicine online. Acknowledgments The authors would like to thank the STOMP course faculty and standardized patients for their support of this project. Additionally, we thank the staff of the Naval Medical Center Portsmouth’s Healthcare Simulation and Bioskills Training Center for their professionalism and dedication to the advancement of military medical simulation. Presentation This study was presented in part as a poster at the American College of Surgeons Accredited Education Institutes Consortium Meeting from March 7–9, 2016, and the 2016 Military Health System Research Symposium, Kissimmee FL. (MHSRS abstract no. 16-1305-1274). Funding No funding was received for this study. The STOMP course was funded through the simulation budget at Naval Medical Center Portsmouth. 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This work is written by (a) US Government employee(s) and is in the public domain in the US. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.
TI - Simulation Training for Operational Medicine Providers (STOMP): Design and Implementation of a Novel Comprehensive Skills-Based Curriculum for Military General Medical Officers 
JF - Military Medicine
DO - 10.1093/milmed/usx140
DA - 2018-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/simulation-training-for-operational-medicine-providers-stomp-design-rd77g6Rsu7
SP - 40
EP - 46
VL - 183
IS - suppl_1
DP - DeepDyve
ER -