Program Profile

SimLEARN Musculoskeletal Training for VHA Primary Care Providers and Health Professions Educators

A simulation-based training curricula applied to the primary care evaluation and management of shoulder and knee pain resulted in improved access to care for veterans and cost savings for the health care system.

Fed Pract. 2020 January;37(01):48-52

Author(s):

Andrea M. Barker, MPAS, PA-C

Jeffrey S. LaRochelle, MD, MPH

Anthony R. Artino Jr, PhD

Scott A. Wiltz, MD, MPH

Laura M. Kim, MD

Michael J. Battistone, MD

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References

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11. O’Dunn-Orto A, Hartling L, Campbell S, Oswald AE. Teaching musculoskeletal clinical skills to medical trainees and physicians: a Best Evidence in Medical Education systematic review of strategies and their effectiveness: BEME Guide No. 18. Med Teach. 2012;34(2):93-102.

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18. Battistone MJ, Barker AM, Grotzke MP, Beck JP, Lawrence P, Cannon GW. “Mini-residency” in musculoskeletal care: a national continuing professional development program for primary care providers. J Gen Intern Med. 2016;31(11):1301-1307.

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20. Battistone MJ, Barker AM, Lawrence P, Grotzke M, Cannon GW. Two-year impact of a continuing professional education program to train primary care providers to perform arthrocentesis. Presented at: 2017 ACR/ARHP Annual Meeting [Abstract 909]. https://acrabstracts.org/abstract/two-year-impact-of-a-continuing-professional-education-program-to-train-primary-care-providers-to-perform-arthrocentesis. Accessed November 14, 2019.

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22. US Department of Veterans Affairs. VHA SimLEARN. https://www.simlearn.va.gov/SIMLEARN/about_us.asp. Updated January 24, 2019. Accessed November 13, 2019.

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Diseases of the musculoskeletal (MSK) system are common, accounting for some of the most frequent visits to primary care clinics.^1-3 In addition, care for patients with chronic MSK diseases represents a substantial economic burden.^4-6Unfortunately, despite the high prevalence and associated costs of these conditions, numerous reports have concluded that primary care providers (PCPs) are not well prepared to effectively address these problems due to gaps in health professions education (HPE) programs.^7-12 Among other effects, overutilization of high-cost diagnostic tools or specialty care providers are increasingly recognized as important drivers of unnecessary spending.^13-16

In response to this clinical training need, the Veterans Health Administration (VHA) developed a portfolio of educational experiences for VHA health care providers and trainees, including both the Salt Lake City and National MSK “mini-residencies.”^17-19 These programs have educated more than 800 individuals. Early observations show a progressive increase in the number of joint injections performed at participant’s VHA clinics as well as a reduction in unnecessary magnetic resonance imaging orders of the knee.^20,21 These findings may be interpreted as markers for improved access to care for veterans as well as cost savings for the health care system.

The success of these early initiatives was recognized by the medical leadership of the VHA Simulation Learning, Education and Research Network (SimLEARN), who requested the Mini-Residency course directors to implement a similar educational program at the National Simulation Center in Orlando, Florida. SimLEARN was created to promote best practices in learning and education and provides a high-tech immersive environment for the development and delivery of simulation-based training curricula to facilitate workforce development.²² This article describes the initial experience of the VHA SimLEARN MSK continuing professional development (CPD) training programs, including curriculum design and educational impact on early learners, and how this informed additional CPD needs to continue advancing MSK education and care.

Methods

The initial vision was inspired by the national MSK Mini-Residency initiative for PCPs, which involved 13 US Department of Veterans Affairs (VA) medical centers; its development, dissemination, and validity evidence for assessment methods have been previously described.^17,18,23 SimLEARN leadership attended a Mini-Residency, observing the educational experience and identifying learning objectives most aligned with national goals. The director and codirector of the MSK Mini-Residency (MJB, AMB) then worked with SimLEARN using its educational platform and train-the-trainer model to create a condensed 2-day course, centered on primary care evaluation and management of shoulder and knee pain. The course also included elements supporting educational leaders in providing similar trainings at their local facility (Table 1).

Curriculum was introduced through didactics and reinforced in hands-on sessions enhanced by peer-teaching, arthrocentesis task trainers, and simulated patient experiences. At the end of day 1, participants engaged in critical reflection, reviewing knowledge and skills they had acquired.

On day 2, each participant was evaluated using an observed structured clinical examination (OSCE) for the shoulder, followed by an observed structured teaching experience (OSTE). Given the complexity of the physical examination and the greater potential for appropriate interpretation of clinical findings to influence best practice care, the shoulder was emphasized for these experiences. Time constraints of a 2-day program based on SimLEARN format requirements prevented including an additional OSCE for the knee. At the conclusion of the course, faculty and participants discussed strategies for bringing this educational experience to learners at their local facilities as well as for avoiding potential barriers to implementation. The course was accredited through the VHA Employee Education System (EES), and participants received 16 hours of CPD credit.