Translational Educational Research

Abstract

Medical education research contributes to translational science (TS) when its outcomes not only impact educational settings, but also downstream results, including better patient-care practices and improved patient outcomes. Simulation-based medical education (SBME) has demonstrated its role in achieving such distal results. Effective TS also encompasses implementation science, the science of health-care delivery. Educational, clinical, quality, and safety goals can only be achieved by thematic, sustained, and cumulative research programs, not isolated studies. Components of an SBME TS research program include motivated learners, curriculum grounded in evidence-based learning theory, educational resources, evaluation of downstream results, a productive research team, rigorous research methods, research resources, and health-care system acceptance and implementation. National research priorities are served from translational educational research. National funding priorities should endorse the contribution and value of translational education research.

Translational science (TS) has been defined historically within the biomedical disciplines. The traditional TS definition involves research that progresses from bench to bedside in three phases. T1 science involves basic laboratory discoveries in the biomedical sciences. T2 science aims to produce evidence of T1 effectiveness at the individual patient level, compare the success of different treatments to identify “the right treatment for the right patient in the right way at the right time,” and translate these results into practice guidelines for patients, clinicians, and policy makers.¹ T3 science addresses health-care delivery, community engagement, and preventive services that produce measureable improvements in the health of individuals and society.¹

The biomedical TS imperative has been expressed for at least a century. In his 1905 Nobel Prize lecture titled “The Current State of the Struggle Against Tuberculosis,”² Robert Koch was prescient about the slow pace of medical TS. Koch complained that the etiology of TB “shared the fate of so many similar cases in medicine, where a long time has also been necessary before old prejudices were overcome and the new facts were acknowledged to be correct by physicians.”²

TS and comparative effectiveness research policies in the United States have been published using a “roadmap” metaphor by the US National Institutes of Health (NIH)^3,4 and the Institute of Medicine.⁵ Complementary work by the US Agency for Healthcare Research and Quality (AHRQ) outlines health-care research priorities.⁶ Other publications describe the mission and goals of the NIH/National Center for Research Resources Clinical and Translational Science Awards program,^7‐9 which are “to transform the conduct of biomedical research in the United States by speeding the translation of scientific discoveries into useful therapies and then developing methods to ensure that those therapies reach patients who need them most.”⁸ A parallel definition states that “translational research fosters the multidirectional and multidisciplinary integration of basic research, patient-oriented research, and population-based research, with the long-term aim of improving the health of the public.”¹⁰

All of these statements about TS policies and priorities focus on biomedical research, education of biomedical scientists, and conventional treatment options. They do not address the value of a skilled workforce in the clinical medical and health professions and the importance of rigorous clinical education for the delivery of effective health care. We assert that human capital, embodied in competent physicians and other health professionals, is an essential feature of TS even though NIH, Institute of Medicine, and AHRQ policies and priorities are silent about the contribution of clinical medical education to health-care delivery.

Medical Education Simulation as TS

Simulation-based medical education (SBME) complements biomedical TS. SBME contributes to TS when it stretches the outcome measurement end point from the simulation education laboratory and in situ teaching settings to better health-care delivery and patient outcomes, just like its biomedical counterparts.^11,12 SBME TS demonstrates, for example, that acquisition of central venous catheter insertion skills by medical residents to mastery standards achieved in the simulation laboratory (T1 science)¹³ transfers to improved patient-care practices (ie, fewer needle passes, arterial punctures, needle adjustments, higher success rates [T2 science]),¹⁴ and improved patient outcomes (ie, an 85% reduction in medical ICU [MICU] catheter-related bloodstream infection rates due to the educational intervention [T3 science]).¹⁵ Other examples of translational outcomes resulting from SBME include skill and knowledge retention over time¹⁶; unexpected, yet welcome, collateral effects that document systemic educational improvement among internal medicine residents due to rigorous training of prior resident cohorts¹⁷; and cost-effectiveness expressed as return on financial investment.¹⁸

The science of health professions education underlies all three phases of the TS model. It produces human capital embodied in an informed, skillful, and ethical workforce of scientists and health professionals who work as individuals and teams. Educational science findings prescribe that many hours of focused deliberate practice¹⁹ combined with rigorous assessment, feedback, and task repetition under controlled domain-specific conditions²⁰ are needed for the initial acquisition of scientific or clinical expertise and to enhance continued development of performance.¹⁹ Educational science is the core of TS, because it produces, sustains, and enriches successive generations of scientists and professionals who advance research and patient care.

SBME, which is different from traditional clinical education because of standardization and a focus on learners rather than patients, is well suited to help physicians acquire a broad range of competencies. The best evidence now available shows that effective SBME has many of the following key features: (1) feedback to individuals and teams, (2) deliberate practice, (3) curriculum integration, (4) outcome measurement, (5) simulation fidelity that resembles the authentic educational professional context, (6) addresses skill acquisition and maintenance, (7) mastery learning, and (8) instructor training.²¹ A recent, meta-analytic, comparative effectiveness study shows that SBME with deliberate practice is far superior to traditional “see one, do one, teach one” clinical education for the purpose of clinical skill acquisition.²²

This article presents an amplified definition of TS, building on a commentary previously published in CHEST.²³ That article states, “Simulation-based training reduces medical error, enhances clinical outcomes, and reduces the cost of clinical care. It is surprising that medical simulation is not routinely integrated into the training curricula of all health-care professionals.”²³ We suggest here that effective health-care TS stems from seamless and cascaded educational research programs that are thematic, sustained, and cumulative. Such research programs not only include T1-T3 studies and beyond, but also embrace implementation science.

Implementation Science

Implementation science (IS) elaborates the customary biomedical focus of T2 and T3 research. It is a novel discipline and also the title of an open-access journal, now in its seventh volume (2012). The journal states its research focus is “the scientific study of methods to promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice, and hence to improve the quality and effectiveness of healthcare. It includes the study of influences on healthcare professional and organisational behaviour.”²⁴ This “is scientifically important because it identifies the behaviour of healthcare professionals and healthcare organizations as key sources of variance requiring improved empirical and theoretical understanding before effective interventions can be reliably achieved.”²⁴ IS studies and seeks to overcome health-care organizational silos and barriers, pockets of cultural inertia, professional hierarchies, and financial disincentives that reduce health-care efficiency and effectiveness. In hospitals and clinics, IS addresses the science of health-care delivery.

Prominent clinician-scientists endorse the importance of IS for patient care and patient safety. To illustrate, Pronovost and colleagues²⁵ stated, “The paradox between health and harm partially stems from our failure to view the delivery of health care as a science.” Further, “The research community appears to believe that discovery of effective therapies is the final endpoint. Few researchers are trained in the science of healthcare delivery, and incentives to undertake such research are anemic.” They concluded, “Such science investigates the uncontrolled and complex world of influencing real-world clinical practice.”²⁵

Recent scholarship by a group of behavioral scientists in the United Kingdom led by Ray Pawson sheds practical light on IS ideas.^26,27 These scholars suggested that adoption and maintenance of an educational intervention such as an SBME curriculum to promote clinical skill acquisition (eg, ventilator patient management) that operates in a busy environment (eg, an MICU) is a complex service intervention (CSI). CSIs are difficult to plan and manage successfully, involve human error and resistance, may upend established clinical habits, and require coordination of professional and technical staff at many levels. A successful CSI in one clinical setting is very difficult to transfer uniformly to other clinical settings due to physical, organizational, and cultural differences. Pawson and colleagues reported that CSIs have seven “defining features,” which are presented with research-based examples in Table 1.

Table 1.

—Defining Features of a CSI

CSIs Have Seven Defining Features26:	Example
1. CSIs are theories grounded on hypotheses that link service delivery…to expected outcomes.	Improved patient-handoff procedures due to simulation-based team training leads to better and safer patient-care practices.28
2. CSIs are active via input from individuals and groups.	Individual and team training in obstetric emergencies produce statistically and clinically significant reductions in birth complications due to shoulder dystocia (brachial plexus injury), low APGAR scores, and neonatal hypoxic-ischemic encephalopathy from oxygen deprivation.29‐31
3. CSIs have a long journey. The sequence of events forms a long implementation chain.	Creating, implementing, and sustaining a SBME TS research program in ACLS skills involved a sequence of steps over time: identify the need32; design, develop, and evaluate the curriculum scientifically32; develop and test outcome measures33; set standards34; revise curriculum to feature mastery learning35; evaluate immediate and long-run results in the simulation environment36; and evaluate outcomes during real hospital codes.37,38
4. CSI implementation chain is often “non-linear and can even go in reverse.”	Traditional clinical education does not improve moral reasoning, a key feature of professionalism, among medical students. “…students faced with increasingly clinical learning situations regressed in moral reasoning. …changes in [moral reasoning] scores could be attributed to the education process rather than to the students’ maturation in age.”39
5. CSIs are fragile…embedded in multiple social systems.	PBL has many definitions and expressions in medical education. “There are many variants of PBL. The context has at least as much effect as the method in determining the success or otherwise of PBL.”40
6. CSIs are “leaky” and prone to be borrowed and adapted.	Several recent reviews show that technology-enhanced education in the health professions is superior to conventional educational methods to produce better knowledge, skill, and behavioral outcomes. However, there are currently no “best methods” or “best uses” for technology-assisted education.41,42
7. CSIs are open systems that feed back on themselves: “…interventions change the conditions that made them work in the first place.”	Steady, unexpected improvement in CVC pretest scores among untrained residents were attributed to a growing number of mastery trained residents in the clinical environment.17

ACLS = advanced cardiac life support; APGAR = appearance, pulse, grimace, activity, respiration; CSI = complex service intervention; PBL = problem-based learning; SBME = simulation-based medical education; TS = translational science.

An example of a CSI of interest to CHEST readers is the Michigan ICU project led by Peter Pronovost.^43‐47 This statewide, patient safety, and quality improvement project “attracted international attention by successfully reducing rates of central venous catheter bloodstream infections.”⁴⁸ This was accomplished in > 100 participating Michigan ICUs. Reports about the Michigan project asserted that its results were achieved chiefly by implementing five evidence-based clinical recommendations from the US Centers for Disease Control and Prevention (CDC). “Four recommendations related to insertion of the catheter: hand washing, using full barrier precautions, cleaning the skin with chlorhexidine, and avoiding the femoral site when possible. The fifth recommendation was to remove unnecessary catheters.”⁴⁴ Project outcomes were evaluated using observational checklists. Note that none of the recommendations mention medical education as a program feature.

A subsequent, qualitative, program evaluation coauthored by Pronovost that was grounded in IS principles was designed to reveal why the Michigan project CSI really worked. This study found that the reasons why the statewide Michigan MICU intervention produced strong results were peer and public pressure toward hospitals and their MICUs to participate and conform, reframing central venous catheter bloodstream infections as a social problem, “using several interventions [including strong doses of medical and nursing education] that functioned in different ways to shape a culture of commitment to doing better in practice,” using data on infection rates as a disciplinary focus, and reliance on the “hard edges” of accountability and professional sanction.⁴⁸ This is a much deeper probe than outcomes gauged by simple checklists. A recent AHRQ policy statement, “Advancing the Science of Patient Safety,”⁴⁹ reinforces IS principles.

Model of Simulation-Based TS

Powerful SBME TS is grounded in research programs that are thematic, sustained, and cumulative. A well-designed thematic SBME TS research program has clinical and implementation (science of health-care delivery) components, leveraging educational processes to produce measureable clinical impact.

What does it take to start and maintain such a program of simulation-based translational medical science? How can medical clinicians, medical educators, and health services researchers unite to achieve translational medical education research goals? Table 2 identifies components of a SBME translational research program. The components include (1) highly motivated health professions learners; (2) curricula grounded in education science with learning goals and objectives that promote deliberate practice, rigorous measurement, feedback, mastery learning, and follow-up assessments; (3) educational resources including simulators, trained faculty, space, and training time; (4) intent to evaluate meaningful downstream results measured in different ways; (5) a research team that shares a variety of attributes that contribute to its productivity and morale; (6) reliance on rigorous quantitative, qualitative, and mixed research methods that produce reliable data that permit valid inferences and decisions; (7) sufficient research resources; and (8) a health-care system that accepts SBME trainees, values and reinforces T1 outcomes, and implements the program scientifically.

Table 2.

—Components of a SBME TS Research Program

Component
Learners
Health professionals in training: individuals and teams
Highly motivated
Curriculum
Goals and learning objectives
Educational activities or interventions
Deliberate practice
Rigorous measurement that yields reliable data
Feedback to learners
Improvement, more deliberate practice, more measurement
Minimum passing standards
Mastery learning
Valid data-based decisions about learners
Follow-up assessment
Educational resources
Simulators appropriate to learning objectives
Trained faculty
Space
Training materials
Training time
Funding to support above
Institutional senior leadership support
Evaluation of downstream results11,12,50
Improved patient-care practices
Patient safety
Improved health-care team work
Better patient outcomes
Skill and knowledge retention
Collateral effects
Cost-effectiveness or return on investment
Distal results: dissemination, adoption, public health impact
Productive research team51‐53
Shared goals, common mission
Organization, planning, regular meetings
Functional diversity
Clear leadership (may change or rotate)
Shared cognition
High standards
Sustained hard work and commitment
Physical proximity
Minimize status differences within the team
Maximize status of the team
Shared activities that breed trust
Frequent attention to authorship issues
Research methods54‐58
Methodologic rigor and variety
Quantitative, qualitative, and mixed-method approaches
Reliable data
Valid inferences and decisions
Research resources
Scientist-leaders and staff
Financing
Research and writing time
Patient records that contain reliable data
Health-care system acceptance and implementation25,48,49,59‐61
Value and reinforce T1a SBME outcomes in situ
Advance science of health-care delivery
Advance science of patient safety
Rigorous implementation science

SBME = simulation-based medical education; TS = translational science.

^aT1 science involves basic laboratory discoveries in the biomedical sciences.

Opportunities in Translational Education Research

Medical education research directed toward TS goals can address a variety of specific aims. Research opportunities focused on SBME include studies on the duration and intensity of deliberate practice, measurement development and refinement, skill maintenance, faculty development, and many others.⁶² Health-care improvement needs to be addressed by translational research programs with or without a foundation in simulation. Key areas needing improvement include interprofessional education and its clinical impact; clinical team training and measurement of its downstream impact on patient care, safety, and outcomes; and enhanced patient safety and quality in a variety of inpatient and outpatient settings. A guiding principle for this work was expressed at the first Research Consensus Summit of the Society for Simulation in Healthcare: “The progress of research depends on building overarching and sustainable research programs that relate individual studies with each other.”⁶³

Translational education research programs would also address national research priorities and serve the national research agenda of the newly formed Patient-Centered Outcomes Research Institute.⁶⁴ The Institute’s statutory criteria for evaluating research questions include “effect on the health of individuals and populations, probability of improvability through research, effect on health care system performance, and rigorous research methods.”⁶⁴ High on the Institute’s list of research priorities is “improving health care systems.”⁶⁴ These criteria for judging patient-centered research and the priority agenda item all conform with goals of translational education research.

Conclusions

Translational education research is one component of TS programs that also include IS to optimally serve goals of patient-care quality and safety and better patient outcomes. Several thematic, simulation-based, education research programs have already demonstrated downstream TS results. This can only be achieved when education translational research is as robust and comprehensive as basic and clinical science translational research programs. The value of SBME translational education research to contribute to US health-care goals and outcomes should be reflected in NIH and AHRQ research-funding priorities.

Abbreviations

AHRQ

Agency for Healthcare Research and Quality

CSI

complex service intervention

IS

implementation science

MICU

medical ICU

NIH

National Institutes of Health

SBME

simulation-based medical education

TS

translational science