Teaching professionalism in graduate medical education: What is the role of simulation?

BACKGROUND: We systematically reviewed the literature concerning simulation-based teaching and assessment of the Accreditation Council for Graduate Medical Education professionalism competencies to elucidate best practices and facilitate further research. METHODS: A systematic review of English literature for "professionalism" and "simulation(s)" yielded 697 abstracts. Two independent raters chose abstracts that (1) focused on graduate medical education, (2) described the simulation method, and (3) used simulation to train or assess professionalism. Fifty abstracts met the criteria, and seven were excluded for lack of relevant information. The raters, 6 professionals with medical education, simulation, and clinical experience, discussed 5 of these articles as a group; they calibrated coding and applied further refinements, resulting in a final, iteratively developed evaluation form. The raters then divided into 2 teams to read and assess the remaining articles. Overall, 15 articles were eliminated, and 28 articles underwent final analysis. RESULTS: Papers addressed a heterogeneous range of professionalism content via multiple methods. Common specialties represented were surgery (46.4%), pediatrics (17.9%), and emergency medicine (14.3%). Sixteen articles (57%) referenced a professionalism framework; 14 (50%) incorporated an assessment tool; and 17 (60.7%) reported debriefing participants, though in limited detail. Twenty-three (82.1%) articles evaluated programs, mostly using subjective trainee reports. CONCLUSION: Despite early innovation, reporting of simulation-based professionalism training and assessment is nonstandardized in methods and terminology and lacks the details required for replication. We offer minimum standards for reporting of future professionalism-focused simulation training and assessment as well as a basic framework for better mapping proper simulation methods to the targeted domain of professionalism.

Patient safety and health policy: a history and review.

Policy initiatives on many fronts have converged to improve patient safety. A major tension that characterizes this process is the attempt to achieve a balance between learning and control in complex systems with technical, social, and organizational components. Efforts to improve learning are marked by better information flow, discovery, flexibility in thinking, embracing of failures as learning opportunities, and core incentives to promote voluntary participation of all stakeholders in the process. Efforts to improve accountability are traditionally marked by public disclosure, meeting of certain widely disseminated standards, availability of performance measures, exposure to legal liability, and compliance with mandated directives (statutes, regulations, accreditation requirements). In some sense, these directions are mutually exclusive. Although a more collaborative regulatory-improvement model would be helpful in creating an industrywide safety culture, it is likely that learning and accountability functions will follow separate tracks. An exception would be policy that stimulates organizations to comply with regulation by showing how well and by what methods they are learning and how others can profit from these experiences. Any approach to improving patient safety should, at a minimum, include a nonpunitive in-depth mechanism for reporting incidents, postincident evaluations for identification of system changes to prevent subsequent occurrences, and state-guaranteed legislative protection from discovery for all aspects of information gathered to improve patient safety. Nonpunitive approaches have yielded useful results in other industries [43]. State and federal courts, state licensing boards, and accrediting bodies such as JCAHO all function to maintain accountability and standards; however, the very fear of existing legal liability or its misapplication are the greatest hurdles to pioneering patient-safety efforts. The health care system needs to transform the existing culture of blame and punishment that suppresses information about errors and adverse events into a culture of safety that focuses on openness and information sharing to improve health care and prevent adverse outcomes. Education and leadership will be most important to creating and sustaining a strong safety culture and arguably the most important defense against preventable harms. Safety culture cannot be legislated, just as the old adage states that it is easier to pull rather than push a piece of spaghetti. Given the imbalances and inefficiencies of market forces in health care, perverse incentives that have strengthened resistance to change, and secrecy when it comes to adverse event information, however, it is likely that policy initiatives will continue to play an important role in the transformation of the industry to more highly reliable, safer levels of care.

Simulation-based medical education: an ethical imperative.

Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these two needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change. Recently, the international patient safety movement and the U.S. federal policy agenda have created a receptive atmosphere for expanding the use of simulators in medical training, stressing the ethical imperative to "first do no harm" in the face of validated, large epidemiological studies describing unacceptable preventable injuries to patients as a result of medical management. Four themes provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. These themes are examined from the perspectives of patients, learners, educators, and society. The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.

Ambulatory patient safety. What we know and need to know.

While safety risks are widespread in ambulatory settings, there has been insufficient attention directed at developing the evidence base that is needed to improve ambulatory safety. In this article, the current state of knowledge about ambulatory safety is reviewed. A research agenda in ambulatory safety is proposed, as well as a series of potential interventions that could be used to improve safety in the ambulatory setting.

Simulation applications for human factors and systems evaluation.

Simulation applications have become increasingly common in health care. A convergence of factors has stimulated this growth, including the rapid advance of enabling technologies, demand for improved outcomes and objectively assessed competencies, and translation of lessons learned from other high-risk industries as a function of the patient safety and quality movements. The bulk of the experience gained and resources expended has been focused on education, training, and assessment of clinicians' knowledge, skills, and attitudes. Simulation methods lend themselves to supporting human factors and systems-level investigations, yet work in health care has, to a large degree, been limited to a few experienced centers, interdisciplinary research teams, and isolated novel studies.

Simulation-based medical education: an ethical imperative.

Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these 2 needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change. Recently, the international patient safety movement and the U.S. federal policy agenda have created a receptive atmosphere for expanding the use of simulators in medical training, stressing the ethical imperative to "first do no harm" in the face of validated, large epidemiological studies describing unacceptable preventable injuries to patients as a result of medical management. Four themes provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. These themes are examined from the perspectives of patients, learners, educators, and society. The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.