‘Live Die Repeat’ simulation for medical students

The ‘Live.Die.Repeat’ (LDR) format for simulation-based education (SBE) involves repetition of scenario segments until adequate learner performance is achieved and emphasises repetitive practice over prolonged postscenario reflective debriefing.¹ We incorporated the LDR format into our medical student simulations and suggest that it can be a useful element in a programmatic simulation curriculum, with appropriate preparation for learners and faculty.

Background

Simulation-based education (SBE) has been widely adopted as a learning method for health professional education and may also be enhanced by the integration of educational games - ‘an instructional method requiring the learner to participate in a competitive activity with preset rules’.² In their ‘Live.Die.Repeat’ (LDR) study, Sunga et al designed a simulation scenario that incorporated gameplay to teach the management of emergent pulmonary conditions to postgraduate emergency medicine trainees.¹ The design was based on recursive objective-based gameplay—‘a serious-game scheme in which participants are allowed infinite lives so that they can achieve predetermined criteria for progression through multiple levels of increasing difficulty’.¹

The LDR format has parallels with rapid cycle deliberate practice (RCDP)³ simulation, a team-based simulation method, emphasising repetitive practice over reflective debriefing, with progressively more challenging rounds, frequent starts and stops and direct coaching. RCDP is well described for ‘algorithmic’ tasks like resuscitation, and the Sunga study was also undertaken with critical care postgraduate trainees in high acuity scenarios. We hypothesised that the format would also be effective for the lower acuity and less technical context of medical student education.

Live Die Repeat simulations for medical students

We incorporated the LDR format into our medical student simulations at the Bond University Medical programme at the Gold Coast, Australia. Bond has a 5-year undergraduate programme with an integrated simulation curriculum, where students in all years participate in scenario-based learning designed to both prepare for clinical practice and to enhance reflection on real world practice. By the final year of the programme, students will have participated in seven or eight scenario-based learning sessions, involving team-based care of typical patients encountered in the relevant rotations and guided reflection with clinician facilitators. Scenarios include both simulated patient and manikin modalities, selected according to the scenario content.

Final year students undertaking their critical care rotations were scheduled to attend a 2-hour LDR simulation session, as part of their rotations, between March and September 2018. Simulated cases were selected to be relevant to final year students in their critical care rotation and had a ‘deteriorating patient’ focus. They included acute dyspnoea, life-threatening arrhythmia, septic shock and acute loss of consciousness secondary to opioid intoxication.

Scenarios were designed or adapted to the LDR format by the simulation educators to provide guidance as to relevant ‘pause’ points for facilitators, confederates and simulated patients (online supplementary file 1). The scenarios used were simpler than those in the original LDR study (designed for postgraduate emergency medicine trainees) and did not have an increasing difficulty level and thus necessitated fewer ‘critical actions’.

Facilitators, nursing confederates and simulated patients were prepared for LDR format delivery through development of an online resource explaining the format and offering a video demonstration of an LDR scenario.

Students were provided with pre-reading prior to the session describing the LDR method and how it would affect their progression through the scenarios. The new methodology was described as akin to the movies Edge of Tomorrow ⁴ or Ground Hog Day.⁵ They were informed about the gameplay and recursive nature of the session and that they could call for a pause at any time if they felt ‘stuck’.

Simulation sessions started with a 10-min prebrief period, involving a standard introductory process, reiteration of the LDR format and an opportunity to answer questions. A group of four to five students participated in each session, two actively taking part in the scenario and the remainder (two to three students) observing via a live video feed. The sessions lasted 35 min including debriefing periods by an experienced facilitator.

The simulation facilitator paused the session at key moments (eg, when a specific goal was achieved or when students were experiencing difficulties) for a short, focused debriefing session. The scenario would then either ‘rewind’ to enable learners to apply their new insights or continue to progress, depending on facilitator and student choice.

Evaluation

Students were invited to provide feedback using the modified version of the Simulation Effectiveness Tool (mSET) described by Elfrink et al.⁶ In addition to the Likert items, there was a single free text question—‘Any further comments on the Live Die Repeat format?’. Participation in the simulation was a core element of the curriculum, but completing the evaluation was optional.

All (n=54) students completed the survey, and results are summarised in figure 1. Responses suggested particular benefit in preparing for critical thinking, recognising challenges and in the simulation debriefings. There was less benefit perceived in understanding pathophysiology of the conditions simulated and in confidence in decision-making. Free text comments were received from 12 of the 54 surveys completed after the LDR format simulation. Most were positive, and a few responses gave specifics as to why these were helpful,

Figure 1.

LDR format—The Modified Simulation Effectiveness Tool (n=54). LDR, Live Die Repeat.

I find these sims much more useful

Very helpful, as able to apply the newly acquired knowledge straight away

I liked being able to fix up my mistakes via the LDR format.

Live Die Repeat allowed me to practice things that I just learnt, consolidating my knowledge.

Discussion

Simulation sessions were well received in this lower acuity, less algorithmic learning context, pitched at the level of medical students. There were no specific comments related to engagement or ‘game play’, perhaps because simulation is already perceived as engaging in standard format and perhaps because there was no explicit competitive element.

The LDR simulations were feasible to run with our current physical setup and simulation delivery environment and with written and online video guidance for facilitators. Our scenario ‘levels’ and predetermined critical actions were just as likely to focus on a clinical handover, explanation to the patient or interaction with a nurse, as they were to focus on ‘ABC’ emergency responses or procedures.

Limitations

The study outcomes were by self-report only. The mSET was used in this study based on the previous work by Sunga and colleagues and the previous validation building work in simulation-based educational evaluation.⁶ There was no formal evaluation of facilitator or simulated patient perceptions of learning process or outcomes, but our faculty informally report high satisfaction with the format, although with a need to modify their debriefing approach.

Conclusion

Educational gaming and RCDP formats appeal to educators on the basis of pedagogical principles and evidence is building for these in practice.⁷ We have demonstrated that this educational appeal is matched by acceptability to undergraduate medical student learners and feasibility for simulation programmes.