Fellowship Accreditation: Experiences From Health Care Simulation Experts.

Background The field of health care simulation continues to grow, accompanied by a proliferation of fellowship programs, leading to fellowship accreditation efforts. There is controversy around the best approach to accreditation. Objective The authors sought to understand perspectives of simulation leaders on fellowship accreditation to best inform the growth and maturation of fellowship accreditation. Methods In 2020, simulation leaders identified through snowball sampling were invited to participate in a qualitative study. During one-on-one semistructured interviews, participants were asked about experiences as simulation leaders and their perspective on the purpose and impact of accreditation. The interviews were audio recorded and transcribed. Thematic analysis informed by a phenomenology framework was performed using a masked open coding technique with iterative refinement. The resulting codes were organized into themes and subthemes. Results A total of 45 simulation experts participated in interviews ranging from 25 to 67 minutes. Participants described discord and lack of consensus regarding simulation fellowship accreditation, which included a spectrum of opinions ranging from readiness for accreditation pathways to concern and avoidance. Participants also highlighted how context drove the perception of accreditation value for programs and individuals, including access to resources and capital. Finally, potential impacts from accreditation included standardization of training programs, workforce concerns, and implications for professional societies. Conclusions Simulation leaders underscored how the value of accreditation is dependent on context. Additional subthemes included reputation and resource variability, balancing standardization with flexibility and innovation, and implications for professional societies.

Should the existing science of teams be applied to fluid teams? An exploration of fluid team effectiveness within the context of healthcare simulation.

Introduction: Fluid teams have become increasingly prevalent and necessary for modern-day issues, yet they differ from more traditional teams, on which much of the current teams literature is based. For example, fluid teams are often comprised of members from different disciplines or organizational divisions who do not have a shared history or future, as they come together to perform a critical, time-sensitive task, and then disband. For these reasons, the mechanisms through which they function and perform may differ from those of more traditional teams, and research is needed to better understand these differences. Methods: To this end, this study utilized critical incident techniques and thematic analysis to examine fluid teams within healthcare, one of the primary contexts in which they are prevalent. Interdisciplinary faculty and students in the medical field who encounter fluid teams within simulation-based education were prompted to reflect on key factors that facilitate or hinder fluid team effectiveness. Results: Primary themes extracted pertained to the conditions fluid teams operate within (e.g., high-stress), the behaviors and emergent states that contribute to their success (e.g., communication), and the KSAO's of value for members of fluid teams to possess (e.g., readiness). These themes were then compared to existing literature, yielding the identification of some similarities but also many important differences between fluid and traditional teams. Discussion: A series of practical recommendations for how to promote fluid team effectiveness is then presented.

Developing Clinician-Educators: a Qualitative Analysis of Structured Reflections from Participatory Teaching in the Final Year in an Integrated Medical School Program.

Objective: This study aimed to describe fourth-year medical students' experiences, recorded and tracked in structured reflective teaching logs (RTLs), as participants in a year-long longitudinal medical student-as-teacher elective. Methods: Thirteen (13) participants from two medical student-as-teacher elective cohorts completed 20 contact hours of self-selected teaching. Participants chose three different learning environments spanning the first 3 years of the medical school curriculum. Reflections were entered into an online spreadsheet with guided prompts (RTL). Open-ended text in the RTLs was analyzed using an inductive qualitative research approach. Open coding was applied across all meaningful segments of text, identifying themes that were validated internally with three co-authors and one methodology expert without formal program involvement. Results: Narratives revealed detailed descriptions and reflections of participant experiences. Analysis revealed eight themes: (1) Joy of Teaching; (2) Teaching Effectiveness; (3) Feedback; (4) Effective Patient-Physician Communication; (5) Assessment; (6) Differential Diagnosis Development; (7) Standardized Case Development; and (8) Training for Teaching in Residency. Conclusion: Fourth-year medical student participants in a longitudinal medical student-as-teacher elective effectively used RTLs from participatory teaching to help facilitate their own development as clinician-educators. Themes identified in RTLs reflect students' awareness of teaching skill requirements and readiness for the next workplace, residency. Informed by situativity theory, formal teaching opportunities in authentic learning environments bestow students with critical formative teaching experience and awareness of the roles as clinician-educators during their undergraduate years.

Targeted organized teaching scripts (TOTS) in the pediatric emergency department.

In the pediatric emergency department (PED), considerable challenges inhibit educational opportunities for residents outside of being precepted. The use of teaching scripts specifically addresses these challenges by allowing faculty to have prepared, hyperfocused content that can be delivered in a short time. We developed a series of teaching scripts for 10 high-yield topics in the PED and assessed their effectiveness at improving educational experiences. Teaching scripts were inconsistently used but well received. Their use also correlated with increased resident satisfaction with clinical teaching. The majority of residents and faculty showed considerable interest in expanding the TOTS program to include additional pediatric emergency medicine topics.

Procedural task trainer gaps in emergency medicine: A rift in the simulation universe.

Objectives: We identified and quantified the gap between emergency medicine (EM) procedures currently taught using simulation versus those that educators would teach if they had better procedural task trainers. Additionally, we endeavored to describe which procedures were taught using homemade models and the barriers to creation and use of additional homemade models. Methods: Using a modified Delphi process, we developed a survey and distributed it to a convenience sample of EM simulationists via the Society for Academic Emergency Medicine Simulation Academy listserv. Survey items asked participants to identify procedures they thought should be taught using simulation ("most important"), do teach using simulation ("most frequent"), would teach if a simulator or model were available ("most needed"), and do teach using simulation with "homemade" models ("most frequent homemade"). Results: Thirty-seven surveys were completed. The majority of respondents worked at academic medical centers and were involved in simulation-based education for at least 6 years. Three procedures ranked highly in overall teaching importance and currently taught categories. We identified four procedures that ranked highly as both important techniques to teach and would teach via simulation. Two procedures were selected as the most important procedures that the participants do teach via simulation but would like to teach in an improved way. We found 14 procedures that simulationists would teach if an adequate model was available, four of which are of high importance. Conclusions: This study captured data to illuminate the procedural model gap and inform future interventions that may address it and meet the overarching objective to create better and more readily available procedure models for EM simulation educators in the future. It offers an informed way of prioritizing procedures for which additional homemade models should be created and disseminated as well as barriers to be aware of and to work to overcome. Our work has implications for learners, educators, administrators, and industry.

From intern to "accepted": A guide to preparing for fellowship in emergency medicine.

Introduction: The number of fellowship options for emergency medicine (EM) physicians continues to expand. While guides exist to help residents explore individual fellowship pathways, we aimed to create a comprehensive guide for all residents considering fellowship. Methods: At the direction of the Society for Academic Emergency Medicine (SAEM) Board, 9 members of the Fellowship Guide Workgroup, including members of the Fellowship Approval Committee, and 2 members of SAEM Residents and Medical Students (RAMS) group collaboratively developed the guide using available evidence and expert opinion when high-quality evidence was unavailable. The guide was reviewed and approved by all members. Results: The guide offers advice to EM residents on how to conceptualize key aspects of their training with respect to preparation for fellowship, including scholarship, teaching, leadership, and electives. Additionally, it offers perspective on selecting a fellowship that matches the resident's interests and goals and successfully applying. Conclusion: This fellowship guide for EM residents considering fellowship summarizes the best currently available advice for residents considering fellowship training after residency.

Accreditation of Simulation Fellowships and Training Programs: More Checkboxes or Elevating the Field?

SUMMARY STATEMENT: As the field of healthcare simulation matures, formal accreditation for simulation fellowships and training programs has become increasingly available and touted as a solution to standardize the education of those specializing in healthcare simulation. Some simulation experts hold opposing views regarding the potential value of simulation fellowship program accreditation. We report on the proceedings of a spirited debate at the 20th International Meeting on Simulation in Healthcare in January 2020. Pro arguments view accreditation as the logical evolution of a maturing profession: improving training quality through standard setting, providing external validation for individual programs, and enhancing the program's return on investment. Con arguments view accreditation as an incompletely formulated construct; burdensome to the "financially strapped" fellowship director, misaligned with simulation fellows' needs and expectations, and confusing to administrators mistakenly equating accreditation with credentialing. In addition, opponents of accreditation postulate that incorporating curricular standards, practice guidelines, and strategies derived and implemented without rigor, supporting evidence and universal consensus is premature. This narrative review of our debate compares and contrasts contemporary perspectives on simulation fellowship program accreditation, concluding with formal recommendations for learners, administrators, sponsors, and accrediting bodies.

Curriculum Design and Scholarship for New Educators: A Professional Development Workshop for Medical Students.

Introduction: Medical students' professional development includes their role as educators. Despite greater opportunities to join medical education curriculum development, medical students' engagement in these activities remains limited. A recent national study on student leadership in curricular change revealed a formal lack of leadership and training in medical education as significant barriers. Medical students' unawareness of how to disseminate curricula as educational scholarship and its value to their careers also restricts the fullness of their formation as educators. Methods: We designed a 3-hour, interactive, project-focused conference workshop for medical students without prior knowledge in curriculum development. Of participants, 64 worked in 10 groups creating medical curricula using Kern's six-step approach in student-facilitated breakout sessions. Completed group projects were presented, including brief action plans for transforming their work into scholarship. The workshop was evaluated using a mixed-methods approach. Results: Of survey respondents, 44 mostly medical students, faculty, and administrators from different institutions rated the workshop as a very positive experience, and the pacing of the breakout groups as effective. A notable increase in self-reported mastery, as measured by learning objectives aligned with Kern's six-step model, was recorded from student respondents as compared to faculty. A sense of readiness to participate in curricular decisions either at the home institution or in individual career paths was evident from narrative comments. Discussion: Our workshop provided medical students with a foundation in curriculum development and educational scholarship. Session design provided flexibility in the pace of breakout sessions and allowed in-depth discussion of educational topics.

Simulation-based emergency medicine education in the era of physical distancing.

Background: The COVID-19 pandemic posed significant challenges to traditional simulation education. Because simulation is considered best practice for competency-based education, emergency medicine (EM) residencies adapted and innovated to accommodate to the new pandemic normal. Our objectives were to identify the impact of the pandemic on EM residency simulation training, to identify unique simulation adaptations and innovations implemented during the pandemic, and to analyze successes and failures through existing educational frameworks to offer guidance on the use of simulation in the COVID-19 era. Methods: The Society for Academic Emergency Medicine (SAEM)'s Simulation Academy formed the SimCOVID task force to examine the impact of COVID-19 on simulation didactics. A mixed-methods approach was employed. A literature search was conducted on the subject and used to develop an exploratory survey that was distributed on the Simulation Academy Listserv. The results were subjected to thematic analysis and examined through existing educational frameworks to better understand successes and failures and then used to generate suggestions on the use of simulation in the COVID-19 era. Results: Thirty programs responded to the survey. Strategies reported included adaptations to virtual teleconferencing and small-group in situ training with a focus on procedural training and COVID-19 preparedness. Successful continuation or relaunching of simulation programs was predicated on several factors including willingness for curricular pivots through rapid iterative prototyping, embracing teleconferencing software, technical know-how, and organizational and human capacity. In specific instances the use of in situ simulation for COVID-19 preparedness established the view of simulation as a "value add" to the organization. Conclusions: Whereas simulation educator's responses to the COVID-19 pandemic can be better appreciated through the lens of iterative curricular prototyping, their successes and failures depended on existing expertise in technological, pedagogical, and content knowledge. That knowledge needed to exist and synergize within a system that had the human and organizational capacity to prioritize and invest in strategies to respond to the rapidly evolving crisis in a proactive manner. Going forward, administrators and educators will need to advocate for continued investment in human and organizational capacity to support simulation-based efforts for the evolving clinical and educational landscape.

Virtual Mentoring: Two Adaptive Models for Supporting Early-career Simulation Investigators in the Era of Social Distancing.

BACKGROUND: Early-career simulation investigators identify limited mentorship as a common barrier to disseminating scholarship and launching a successful academic career in emergency medicine (EM). Conferences often bridge this gap, but the COVID-19 pandemic has forced their indefinite delay. Virtual solutions are needed to capitalize on the breadth of national simulation research experts and grow mentorship in a postpandemic world. METHODS: We developed two complementary innovations to facilitate scholarship development and minimize COVID-associated career challenges resulting from social distancing requirements. The e-fellows forum (FF) provides a capstone experience for works-in-progress and the e-consultation service (CS) supports simulation research during the earlier project stages of design and development. In conjunction with the Society for Academic Medicine's Simulation Academy, we applied videoconferencing technology for both of these novel, virtual innovations. We analyzed corresponding chat transcripts and detailed field notes for emerging themes. In addition, we collected quantitative data via participant surveys regarding their experiences and impact on their projects. RESULTS: Nine simulation fellows presented at the FF and seven junior simulation investigators participated in the CS sessions. Most preferred the virtual format (56% FF, 66% CS) and found the sessions to be helpful in project advancement (66% FF, 100% CS). COVID-19 affected most projects (89% FF, 67% CS). We identified three themes via qualitative analysis: design concerns and inquiries, validation or support shown by mentors and peers, and professional cohesion. CONCLUSIONS: Participants felt that both virtual mentorship innovations advanced their simulation research projects and fostered a sense of professional cohesion within a greater community of practice. These benefits can be powerful at a time where simulation researchers in EM feel disconnected in an era of social distancing. Our future work will include adaptations to a hybrid model with both virtual and in-person modalities as well as creation of more e-mentorship opportunities, thus broadening the early-career simulation research community of practice.

Occult Sepsis Masked by Trauma-Exploration of Cognitive Biases Through Simulation With Emergency Medicine Residents.

Introduction: There is a paucity of simulation literature and curricula addressing cognitive bias and the skills necessary to overcome this common source of clinical error. We designed a scenario for emergency medicine (EM) residents with the intent to trigger an anchoring bias as a nidus for conversation about metacognition. Methods: We implemented this case for teams of two to three PGYs 1-5, including both EM and EM/internal medicine residents within a longitudinal simulation curriculum. The case was designed to simulate a major trauma wherein evaluation according to standard advanced trauma life support principles failed to identify a traumatic injury to explain the patient's hemodynamic instability. Residents had to reorient their thought process towards other etiologies of shock, ultimately identifying sepsis as the driving force behind the trauma. The scenario ran over 10-15 minutes followed by a 30-minute debrief. Case satisfaction and the success of various learning objectives were assessed via a postsimulation survey. Results: Forty-four EM and combined EM/IM residents ranging from PGY 1-5 participated in the simulation over a 5-week period. Nearly 82% of respondents expressed an overall satisfaction with the case. About 76% felt the case succeeded in contributing to their understanding of cognitive biases. Discussion: The implementation of misdirection in this simulation was an effective means by which to engage learners in education about cognitive biases.

Mechanical, Team-Focused, Video-Reviewed Cardiopulmonary Resuscitation Improves Return of Spontaneous Circulation After Emergency Department Implementation.

Background Outcomes in cardiac arrest remain suboptimal. Mechanical cardiopulmonary resuscitation (CPR) has not demonstrated clear clinical benefit; however, video review provides the capability to monitor CPR quality and provide constructive feedback to individuals and teams to improve their performance. The aim of our study was to evaluate cardiac arrest outcomes before and after initiation of a mechanical, team-focused, video-reviewed CPR intervention. Methods and Results In 2018, our emergency department began using mechanical CPR; a new team-focused strategy with nurse-led Advanced Cardiovascular Life Support; and biweekly, multidisciplinary video review of cardiac arrests. A revised approach to resuscitation was generated from a performance improvement session, and in situ simulation was used to disseminate our approach. The primary outcome of this study was the return of spontaneous circulation rate before and after our mechanical, team-focused, video-reviewed CPR intervention. Secondary outcomes included survival to admission and discharge. Multivariable logistic regression modeling was used. The pre- and postintervention groups were similar at baseline. A total of 248 patients were included in our study (97 before and 151 after mechanical, team-focused, video-reviewed CPR). Return of spontaneous circulation was higher in the intervention group (41% versus 26%; P=0.014). There were nonsignificant increases in survival to admission (26% versus 20%; P=0.257) and survival to discharge (7% versus 3%; P=0.163). After controlling for covariates, the odds of return of spontaneous circulation remained higher after the intervention (odds ratio, 2.11; 95% CI, 1.14-3.89). Conclusions Implementation of our mechanical, team-focused, video-reviewed CPR intervention for cardiac arrest patients in our emergency department improved return of spontaneous circulation rates. Survival to hospital admission and discharge did not improve.

Applying Educational Theory and Best Practices to Solve Common Challenges of Simulation-based Procedural Training in Emergency Medicine.

OBJECTIVES: Procedural competency is an essential prerequisite for the independent practice of emergency medicine. Multiple studies demonstrate that simulation-based procedural training (SBPT) is an effective method for acquiring and maintaining procedural competency and preferred over traditional paradigms ("see one, do one, teach one"). Although newer paradigms informing SBPT have emerged, educators often face circumstances that challenge and undermine their implementation. The goal of this paper is to identify and report on best practices and theory-supported solutions to some of these challenges as derived using a process of expert consensus building and reviews of the existing literature on SBPT. METHODS: The Society for Academic Emergency Medicine (SAEM) Simulation Academy SBPT Workgroup convened approximately 8 months prior to the 2019 SAEM Annual Meeting to perform a review of the literature and participate in a consensus-building process to identify solutions (in the form of best practices and educational theory) to these challenges faced by educators engaging in SBPT. RESULTS AND ANALYSIS: Thirteen distinct educational challenges to SBPT emerged from the expert group's primary literature reviews and consensus-building processes. Three domains emerged upon further analysis of the 13 challenges: learner, educator, and curriculum. Six challenges within the "learner" domain were selected for comprehensive discussion in this paper, as they were deemed representative of the most common and most significant threats to ideal SBPT. Each of the six challenges aligns with one of the following themes: 1) maximizing active learning, 2) maintaining learner engagement, 3) embracing learner diversity, 4) optimizing cognitive load, 5) promoting mindfulness and reflection, and 6) emphasizing deliberate practice for mastery learning. Over 20 "special treatments" for mitigating the impact of the 13 challenges were derived from the secondary literature search and consensus-building process prior to and during the preconference workshop; 11 of these that best address the six learner-centered challenges are explored, including implications for educators involved in SBPT. CONCLUSIONS/IMPLICATIONS FOR EDUCATORS: We propose multiple consensus-generated solutions (in the form of best practices and applied educational theory) that we believe are suitable and well aligned to overcome commonly encountered learner-centered challenges and threats to optimal SBPT.

Utilization of high-fidelity simulation to address challenges with the basic science immunology education of preclinical medical students.

BACKGROUND: Immune function and dysfunction are highly complex basic science concepts introduced in the preclinical medical school curriculum. A challenge for early learners is connecting the intricate details and concepts in immunology with clinical manifestations. This impedes relevance and applicability. The impetus in medical education reform is promoting consolidation of basic science and clinical medicine during the first two years of medical school. Simulation is an innovation now widely employed in medical schools to enhance clinical learning. Its use in basic science curriculums is largely deficient. The authors piloted simulation as a novel curricular approach to enhance fundamental immunology knowledge and clinical integration. METHODS: The authors introduced a Primary Immunodeficiency Disease (PIDD) simulation during a basic science immunology course for second-year medical students at the Zucker School of Medicine at Hofstra/Northwell. The simulation tasked small groups of students with evaluating, diagnosing and managing an infant with previously undiagnosed immunodeficiency. Joint facilitation by clinical and science faculty during terminal debriefings engaged students in Socratic discussion. Debriefing aimed to immerse basic science content in the context of the clinical case. Students completed a post-simulation Likert survey, assessing utility in reinforcing clinical reasoning, integration of basic science and clinical immunology, enhanced knowledge and understanding of immunodeficiency, and enhanced learning. A summative Immunodeficiency Objective Structured Clinical Examination (OSCE) question was created by faculty to assess students' recognition of a PIDD and clinical reasoning. RESULTS: The simulation was well received by students with > 90% endorsing each of the objectives on the post-simulation survey. The authors also determined a statistically significant score variance on the summative OSCE question. Higher scores were achieved by the cohort of students completing the OSCE post-simulation versus the cohort completing the OSCE pre-simulation. CONCLUSIONS: The innovative use of simulation in a highly complex basic science immunology course provides relevance and consolidation for preclinical learners. Additional data will be collected to continuously assess application of concepts and proficiency stemming from this novel curricular intervention. The authors advocate the initiation and/or expansion of simulation in non-clinical basic science courses such as immunology to bridge the gap between theory and practice.

Simulation-based Remediation in Emergency Medicine Residency Training: A Consensus Study.

INTRODUCTION: Resident remediation is a pressing topic in emergency medicine (EM) training programs. Simulation has become a prominent educational tool in EM training and been recommended for identification of learning gaps and resident remediation. Despite the ubiquitous need for formalized remediation, there is a dearth of literature regarding best practices for simulation-based remediation (SBR). METHODS: We conducted a literature search on SBR practices using the terms "simulation," "remediation," and "simulation based remediation." We identified relevant themes and used them to develop an open-ended questionnaire that was distributed to EM programs with experience in SBR. Thematic analysis was performed on all subsequent responses and used to develop survey instruments, which were then used in a modified two-round Delphi panel to derive a set of consensus statements on the use of SBR from an aggregate of 41 experts in simulation and remediation in EM. RESULTS: Faculty representing 30 programs across North America composed the consensus group with 66% of participants identifying themselves as simulation faculty, 32% as program directors, and 2% as core faculty. The results from our study highlight a strong agreement across many areas of SBR in EM training. SBR is appropriate for a range of deficits, including procedural, medical knowledge application, clinical reasoning/decision-making, communication, teamwork, and crisis resource management. Simulation can be used both diagnostically and therapeutically in remediation, although SBR should be part of a larger remediation plan constructed by the residency leadership team or a faculty expert in remediation, and not the only component. Although summative assessment can have a role in SBR, it needs to be very clearly delineated and transparent to everyone involved. CONCLUSION: Simulation may be used for remediation purposes for certain specific kinds of competencies as long as it is carried out in a transparent manner to all those involved.

The Reflective Teaching Log (RTL): Effective Documentation of Participatory Teaching Requirements.

We created a reflective teaching log for a student-as-teacher elective to track students' required participatory teaching and to provide a mechanism for reflective evaluation. This Minute Paper-based log is easy to use and can be adapted to similar programs capturing insights of students' teaching experiences and supports reflective learning.