There is an irreversible trend of pediatric cardiovascular doctors needing to provide high-quality care to children, which means that developing a full range of knowledge, skills, and professionalism is necessary (1). Deficiencies in any one of these aspects will dramatically affect the outcomes for pediatric cardiovascular patients. However, in some developing countries, reports from both teachers and residents show that there is a big gap between goals and reality. The mastery, retention, and application of knowledge and skills among residents are lower compared to senior doctors due to their relatively short clinical working time. The cultivation of professionalism depends more on personal contact with the clinical environment. The relatively low level of knowledge and skills among residents leads to their lack of self-confidence in dealing with clinical problems, which further limits their abilities in all aspects. The need for an effective educational model that can simulate the real medical environment with high-fidelity is urgent. In recent years, simulation-based medical education (SBME) has been applied to pediatric teaching to improve this situation in some developed regions of China and was reported to be effective (2). SBME uses simulators or humans as substitutes for real patients and provides an educational environment for educators to use—a real but well-controlled clinical experience, simulating real-life patient care (3). It was reported to be well suited for both high-risk and low-volume clinical scenarios, such as pediatric cardiovascular medicine (3). The knowledge and skills required in these scenarios are rarely practiced during clinical care and can instead be practiced frequently in simulation scenarios without endangering patients. The key to a simulation curriculum is the integration of the most compatible model, which has been a major challenge for pediatric SBME for the past 20 years. A compatible model will improve the effectiveness of the simulation curriculum, while an inappropriate teaching model will result in a waste of time and resources. The two main features of the SBME facility's effective teaching are providing debriefings and repeated practices, according to the findings of a recent system analysis (4). Debriefings are fairly important, and various studies have shown that they can improve learning efficiency and memory retention in SBME (5, 6). SBME with repeated practices is better than those without them in skills acquisition (7). Our study tried to combine the two merits of SBME in a novel model to make full use of them.

Acute fulminant myocarditis (AFM) is rare inflammatory heart disease. The overall incidence of acute myocarditis was 1.4–2.1 per 100,000 children, and 22.8–44.1% of acute myocarditis was classified as AFM, according to a study from 2007 to 2016 conducted in Korea and a study from 2012 to 2018 conducted in Japan (8, 9). However, a significant increase has been found in the incidence rate of AFM over time (8). In particular, AFM in children has been reported to lead to a higher mortality rate than in adults (10). A retrospective observational study of children showed that the mortality related to AFM was 24.1%, which is 41.3 times higher than that of non-fulminant myocarditis (9). AFM has a sudden onset and rapidly develops into heart failure, cardiogenic shock, fatal arrhythmia, or multi-organ failure. Its early symptoms are non-specific, including abdominal pain, vomiting, fatigue, syncope, and convulsions (11), often leading to misdiagnoses (12). The targeted history collection, physical examination, and laboratory tests and imaging (myocardial injury biomarkers, electrocardiogram, echocardiography, cardiac magnetic resonance, etc.) are helpful for early identification and differential diagnosis (11). The management strategy of AFM is to maintain stable hemodynamics and adequate organ perfusion. Even with active medications (intravenous immunoglobulin or glucocorticoids) and supportive therapy (fluid resuscitation or anti-arrhythmic treatment), some patients will still present lactic acidosis and low peripheral perfusion. The only way to improve the survival rate is to maintain the children's circulation with extracorporeal membrane oxygenation (ECMO). According to data from the Extracorporeal Life Support Organization in 2018, AFM had the highest survival rate among all disease types supported by ECMO (up to 76%) and a short hospitalization duration (8 days). The long-term cardiac function of these children during follow-up was satisfactory (13).

We can see that AFM is a disease that is easily misdiagnosed. Early diagnosis and targeted therapy will, thus, significantly improve patients' prognoses. Appropriate management of a child with AFM requires doctors to have related knowledge, skills, and professionalism (communication, cooperation, and so on). However, the chance for residents to understand AFM in clinical practice is very low due to its low incidence rate. Therefore, taking AFM in children as an example, our team developed a novel simulation course with the segmented model characterized by providing debriefings and repeated practices and applied it to the education of residents. The main aim was to build a bridge between pediatric cardiovascular residents and clinical diseases.

Although there is still a long way to go in the training of cardiovascular pediatricians, particularly in developing countries such as China, we have been working hard to cultivate qualified pediatricians in three areas: knowledge, clinical skills, and professionalism (14). This is necessary to provide qualified patient care. The ultimate goal of this education is to improve the health statuses of the patients and the community (14). There are common obstacles among some pediatric cardiovascular residents regarding the retention of knowledge, application of clinical skills, and embodiment of professionalism, which brings great challenges to the pediatric cardiovascular residents' training program. The ideal teaching mode should transfer knowledge, skills, and professionalism in the process of medical education in order to fully develop these aspects. The emergence of SBME has brought a new dawn, but the best teaching model is still being explored (3). We tried a novel simulation curriculum with a segmented model, hoping to improve the teaching effectiveness.

First, qualified pediatric cardiovascular doctors must have rich professional knowledge and proficient clinical skills. For example, to manage children with AFM well, pediatric cardiovascular doctors need to master the disease's incidence rate, etiology, clinical features, management, and prognosis. Our course focused on the knowledge related to the diagnosis and therapy of AFM and the related clinical skills. There were significant differences in the focus areas of the three segments. At the knowledge level, the first segment focused on the early recognition of AFM in children, the second segment focused on the preliminary emergency management, and the third segment focused on the indications for ECMO. At the skill level, the first segment focused on the oxygen therapy strategy, the second segment focused on various emergency labs and imaging, and the third segment focused on the use of defibrillators. SBME is a powerful tool for acquiring knowledge and improving skills, and previous studies have shown its ability in the training of pediatricians (15, 16). In our course, we organically integrated these contents into different segments and delivered focused knowledge and skills training in each segment. From the teacher's point of view, the simulation design was more focused, the simulation running was more purposeful, and the debriefing was timelier. From the residents' point of view, the training was shorter, there was less consent, and quicker feedback was also preferable. The design was in line with the teaching principle of moving along step-by-step. Although the content, teachers, pre-course preview were the same, the knowledge and skill assessment outcomes of the two groups were significantly different. The gap in the knowledge and skill scores between the two groups was as high as 30 points, which was very surprising.

Secondly, professionalism is necessary for pediatric cardiovascular specialists and has attracted more and more attention. Courses that focus only on diseases are no longer suitable for medical education. The American Association of Medical Colleges has established a team of experts to address the challenges in medical education as part of the ongoing Medical School Objectives Project (17). The American Academy of Pediatrics has also recently issued professional quality standards for pediatricians (18). Pediatric cardiovascular patients have unique characteristics, such as poor self-expression, low emotional control, intolerance to disease, non-compliance with examination and treatment, and strong dependency on their parents. The family members of the affected children are prone to be anxious and doubt the medical staff. Many studies have shown the effectiveness of health communication interventions in improving doctor-patient/parent relationships and reducing non-compliance. The benefits of doctor-patient communication may exceed these short-term outcomes, as demonstrated by the cases of other adult chronic diseases (19). In addition, the condition of pediatric cardiovascular patients can change rapidly, so the demand for doctor professionalism, including responsibility, teamwork, and crisis resource management, is also very prominent. However, for a long time, courses on professionalism have been rather empty and boring. Recently, SBME has been reported to have been applied to improve professionalism, but the effect has not been confirmed (20). Our study found that the segmented simulation model was helpful for the professionalism training of pediatricians. In the teaching objectives of each segment, we added professionalism training (including teamwork, communication, and so on). Based on the importance of repeated stimulation (cycles of running and debriefing) for the retention of residents' memory and the cultivation of professionalism awareness, the residents' professionalism significantly improved after multiple segments of training. We found that compared with the control group, residents in the experimental group significantly improved in terms of respecting their patients, protecting patient privacy, and communication.

Residents about to enter clinical work have anxiety related to it. In the beginning, residents often lack sufficient abilities in history recording, physical examination, and diagnostic skills, resulting in a lack of confidence in their performers. They often suffer from psychological problems (stress and anxiety) due to the responsibility they have for patients. Significant stress, high anxiety, and low self-confidence increase the possibility of errors and, thus, harm the success of clinical practice (21). It is necessary to improve the ability of those engaging in patient care through various clinical experiences in a safe environment. Residents with rich medical experience showed confidence in patient care, while residents with high confidence also showed improvement in their clinical skills. In other words, confidence increases as they gain experiences (22). For residents who have limited opportunities to face real patients, it is necessary to provide an environment similar to the real clinical situation to help them better prepare themselves for clinical practice (22). This situation is particularly prominent among young pediatric cardiovascular residents because the severity of the cardiovascular disease is always higher than other diseases. SBME provides an environment very similar to the clinical setting so that students can experience the actual clinical management. The human patient simulators in our study are new and effective teaching models, which have been widely used in medical education (3). Human patient simulators allow residents to experience low-frequency or high-risk scenarios safely and improve their knowledge, skills, and professionalism (23). In particular, with the spread of Corona Virus Disease 2019, the number of hospitalized children has decreased rapidly, and the opportunity for medical residents has decreased as well. In this case, human patient simulators can be actively used as an alternative method to improve the confidence of residents. In addition, anxiety occurring under specific circumstances or stimuli can be reduced through repeated contact (24). Some studies have found that high-fidelity simulation experience, especially repeated contact simulation, can decrease the anxiety and self-confidence of medical students (22, 25). In this study, we found that the residents' self-confidence in mastering knowledge in the experimental group was better than that in the control group. Residents received feedback, repeated similar but more difficult tasks, and saw their progress, which further improved feelings of competence and made learners more welcoming to feedback (5).

Our study proved the feasibility and effectiveness of a simulation curriculum with the segmented model for the first time. The knowledge, skill, and professionalism performance of the residents were significantly improved by applying the novel model. In addition, it also increased the residents' self-confidence. In the analysis of the satisfaction with the teachers, the two groups were comparable in simulation design, the running, and the debriefings. This indicated that the enhanced effectiveness of the experimental group came from the multiple-segmented model of simulation itself rather than from the teacher's skills. The design of the case went deeper step-by-step, which not only aroused residents' interest and self-confidence but also made full use of the two SBME metrics, thereby achieving greater teaching effectiveness.

Our study has some limitations. First, our research lacks the comparison of the patients' improvement after the training of residents through the traditional and novel models, respectively. We will follow up in the future with further studies focused on this area, which will provide more information about the teaching effectiveness of the novel model. Second, the follow-up period is short and does not fully reflect the effect of the long-term retention of knowledge and skills through the novel simulation teaching model. We will extend the follow-up period in our future work to further analyze it. In addition, although the novel simulation curriculum received positive feedback, the findings were only based on one teaching practice. We will, thus, conduct more teaching practices with more participants in future studies to support the findings reported in this study. Finally, although it appeared that the professionalism performance of residents improved based on the qualitative results, there was a lack of quantitative assessment. We will try to develop a more scientific evaluation system in the future.

In conclusion, the simulation curriculum with the novel segmented model could improve the knowledge, skills, and professionalism performance of pediatric cardiovascular residents and enhance their self-confidence. The course received positive feedback, which is worthy of further promotion and application. In future research, we plan to apply this novel simulation model to other pediatric curricula and develop a series of coherent curriculum systems. We will promote it among more pediatric teachers and students, hoping to improve the service quality of pediatric medical workers. Second, after the training, we will regularly follow up on the clinical performance of residents, the improvement and satisfaction of patients, and give feedback to residents and teachers in a timely manner. In addition, we will optimize the assessment system, including a multidimensional evaluation of resident performance, hoping to reflect the teaching effect of curricula and the learning effect of residents through a more reliable method.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

The studies involving human participants were reviewed and approved by the Ethics Committee of the Children's Hospital, School of Medicine, Zhejiang University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

YY collected the data, guided the simulation course practice, and wrote the draft. L-FT, C-ZH, and J-HM performed the statistical analysis and revised the manuscript. Y-XH designed the study and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

The Major Project of New Generation Artificial Intelligence, Scientific and Technological Innovation 2030: Application Research of Virtual Standard Pediatric Patient Model (Ministry of Science and Technology of the People's Republic of China) (2021ZD0113505). The Second Batch of Industry-University-Education Collaboration Projects: Exploration and Practice of Virtual Reality Augmented Technology in Pediatric Intubation Education (Ministry of Education of the People's Republic of China) (202102177013). The General Project: Development and Application of Advanced Curriculum of Pediatric Emergency and Critical Care Based on High-Fidelity Simulators (Zhejiang Provincial Health Commission) (2021427236).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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