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An open access peer-reviewed journal in neurologic and neuroscience education
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December 2022; 1 (2) Research ArticleOpen Access

Education Research: High-Fidelity Simulation to Evaluate Diagnostic Reasoning Reveals Failure to Detect Viral Encephalitis in Medical Trainees

Melissa B. Pergakis, View ORCID ProfileWan-Tsu W. Chang, Camilo A. Gutierrez, Benjamin Neustein, Jamie E. Podell, View ORCID ProfileGunjan Parikh, Neeraj Badjatia, Melissa Motta, View ORCID ProfileDavid P. Lerner, View ORCID ProfileNicholas A. Morris
First published November 17, 2022, DOI: https://doi.org/10.1212/NE9.0000000000200020
Melissa B. Pergakis
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
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Wan-Tsu W. Chang
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
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  • ORCID record for Wan-Tsu W. Chang
Camilo A. Gutierrez
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
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Benjamin Neustein
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
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Jamie E. Podell
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
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Gunjan Parikh
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
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Neeraj Badjatia
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
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Melissa Motta
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
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David P. Lerner
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
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Nicholas A. Morris
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
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Citation
Education Research: High-Fidelity Simulation to Evaluate Diagnostic Reasoning Reveals Failure to Detect Viral Encephalitis in Medical Trainees
Melissa B. Pergakis, Wan-Tsu W. Chang, Camilo A. Gutierrez, Benjamin Neustein, Jamie E. Podell, Gunjan Parikh, Neeraj Badjatia, Melissa Motta, David P. Lerner, Nicholas A. Morris
Neurol Edu Dec 2022, 1 (2) e200020; DOI: 10.1212/NE9.0000000000200020

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Abstract

Background and Objectives Delays in treatment of both herpes simplex virus (HSV) encephalitis and seizures are associated with poor patient outcomes, but many physicians fail to recognize HSV despite classic presenting symptoms. Our goal was to assess trainee performance in a simulation-based case to recognize HSV encephalitis as the underlying etiology of refractory status epilepticus.

Methods This is a prospective, observational, single-center simulation-based study of participants ranging from subinterns to attending physicians managing a patient with viral encephalitis complicated by nonconvulsive status epilepticus. Using a modified Delphi approach, we developed a list of critical actions. The primary outcome measure was critical action item sum score. We compared level of training and performance using analysis of variance as validity evidence to support our findings.

Results Fifty-nine trainees completed the simulation. The mean sum of critical actions completed was 13.9/25 (56%). Eighty percent of trainees administered an appropriately dosed benzodiazepine, and 97% administered a second-line agent. Despite 88% of trainees obtaining a lumbar puncture, only 47% recognized viral encephalitis as the most likely diagnosis with 36% starting appropriate treatment. There was significant effect of training level on critical action sum score (level 1 mean score [SD] = 10.8 [1.5] vs level 2 mean score [SD] = 12.2 [2.5] vs level 3 mean score [SD] = 13.9 [3.0] vs level 4 mean score [SD] = 18.2 [3.2], p < 0.001, R2 = 0.38).

Discussion Although initial seizure treatment was sufficient, failure to recognize HSV encephalitis was common with few trainees initiating appropriate treatment potentially leading to poor outcomes in real-life scenarios. High-fidelity simulation holds promise as an assessment tool in identifying trainee knowledge gaps and why classic clinical cases escape trainee diagnosis.

Glossary

ETT=
endotracheal tube;
HSV=
herpes simplex virus;
ICC=
intraclass correlation;
PGY=
postgraduate year

Footnotes

  • Go to Neurology.org/NE for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Received by Neurology: Education

  • Submitted and externally peer reviewed. The handling editor was Roy Strowd III, MD, MEd, MS.

  • Received March 18, 2022.
  • Accepted in final form September 14, 2022.
  • © 2022 American Academy of Neurology

This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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