Over the past two decades, there has been an exponential and enthusiastic adoption of simulation in healthcare education internationally. Medicine has learned much from professions that have established programs in simulation for training, such as aviation, the military and space exploration. Increased demands on training hours, limited patient encounters, and a focus on patient safety have led to a new paradigm of education in healthcare that increasingly involves technology and innovative ways to provide a standardized curriculum. A robust body of literature is growing, seeking to answer the question of how best to use simulation in healthcare education. Building on the groundwork of the Best Evidence in Medical Education (BEME) Guide on the features of simulators that lead to effective learning, this current Guide provides practical guidance to aid educators in effectively using simulation for training. It is a selective review to describe best practices and illustrative case studies. This Guide is the second part of a two-part AMEE Guide on simulation in healthcare education. The first Guide focuses on building a simulation program, and discusses more operational topics such as types of simulators, simulation center structure and set-up, fidelity management, and scenario engineering, as well as faculty preparation. This Guide will focus on the educational principles that lead to effective learning, and include topics such as feedback and debriefing, deliberate practice, and curriculum integration - all central to simulation efficacy. The important subjects of mastery learning, range of difficulty, capturing clinical variation, and individualized learning are also examined. Finally, we discuss approaches to team training and suggest future directions. Each section follows a framework of background and definition, its importance to effective use of simulation, practical points with examples, and challenges generally encountered. Simulation-based healthcare education has great potential for use throughout the healthcare education continuum, from undergraduate to continuing education. It can also be used to train a variety of healthcare providers in different disciplines from novices to experts. This Guide aims to equip healthcare educators with the tools to use this learning modality to its full capability.
BACKGROUND: Growth of the foreign-born population in the U.S. has led to increasing numbers of limitedEnglish-proficient (LEP) patients. Innovative medical interpreting strategies, including remote simultaneous medical interpreting (RSMI), have arisen to address the language barrier. This study evaluates the impact of interpreting method on patient satisfaction.METHODS: 1,276 English-, Spanish-, Mandarin-, and Cantonese-speaking patients attending the primary care clinic and emergency department of a large New York City municipal hospital were screened for enrollment in a randomized controlled trial. Language-discordant patients were randomized to RSMI or usual and customary (U&C) interpreting. Patients with language-concordant providers received usual care. Demographic and patient satisfaction questionnaires were administered to all participants.RESULTS: 541 patients were language-concordant with their providers and not randomized; 371 were randomized to RSMI, 167 of whom were exposed to RSMI; and 364 were randomized to U&C, 198 of whom were exposed to U&C. Patients randomized to RSMI were more likely than those with U&C to think doctors treated them with respect (RSMI 71%, U&C 64%, p<0.05), but they did not differ in other measures of physician communication/ care. In a linear regression analysis, exposure to RSMI was significantly associated with an increase in overall satisfaction with physician communication/care (β 0.10, 95% CI 0.02-0.18, scale 0-1.0). Patients randomized to RSMI were more likely to think the interpreting method protected their privacy (RSMI 51%, U&C 38%, p<0.05). Patients randomized to either arm of interpretation reported less comprehension and satisfaction than patients in language-concordant encounters. CONCLUSIONS:While not a substitute for languageconcordant providers, RSMI can improve patient satisfaction and privacy among LEP patients. Implementing RSMI should be considered an important component of a multipronged approach to addressing language barriers in health care.
Cellular activation is critical for the propagation of human immunodeficiency virus type 1 (HIV-1) infection. It has been suggested that truly naive CD4+ T cells are resistant to productive HIV-1 infection because of their constitutive resting state. Memory and naive CD4+ T-cell subsets from 11 HIV-1-infected individuals were isolated ex vivo by a combination of magnetic bead depletion and fluorescence-activated cell sorting techniques with stringent criteria of combined expression of CD45RA and CD62L to identify naive CD4+ T-cell subsets. In all patients HIV-1 provirus could be detected within naive CD45RA+/CD62L+ CD4+ T cells; in addition, replication-competent HIV-1 was isolated from these cells upon CD4+ T-cell stimulation in tissue cultures. Memory CD4+ T cells had a median of fourfold more replication-competent virus and a median of sixfold more provirus than naive CD4+ T cells. Overall, there was a median of 16-fold more integrated provirus identified in memory CD4+ T cells than in naive CD4+ T cells within a given patient. Interestingly, there was a trend toward equalization of viral loads in memory and naive CD4+ T-cell subsets in those patients who harbored CXCR4-using (syncytium-inducing) viruses. Within any given patient, there was no selective usage of a particular coreceptor by virus isolated from memory versus naive CD4+ T cells. Our findings suggest that naive CD4+ T cells may be a significant viral reservoir for HIV, particularly in those patients harboring CXCR4-using viruses.
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