SEARCH

SEARCH BY CITATION

Keywords:

  • simulation;
  • continuing medical education;
  • lifelong learning and self-assessment;
  • procedural skills;
  • clinical skills

As co-chairs of the 2008 Academic Emergency Medicine (AEM) Consensus Conference, we asked, “What are the unique advantages that emergency medicine (EM) brings to the field of simulation, and how can simulation help define and ensure expert clinical practice for all emergency department (ED) patients, all the time?” In addition to obvious applications in EM teaching programs, we believe that EM is uniquely positioned to pioneer simulation-based training as one component of ongoing continuing medical education (CME). Piloting such an approach among practicing emergency physicians (EPs) might also help inform the use of simulation as part of the Maintenance of Certification process now endorsed by all member boards of the American Board of Medical Specialties. We present here our own personal view, which emerged during the Consensus Conference, on the potential for a simulation-based CME network in EM.

Rationale

  1. Top of page
  2. Rationale
  3. Barriers and opportunities
  4. simulation-based CME
  5. A Simulation network
  6. THE TRAINING SESSION
  7. Precedent and Potential
  8. References

Peer review is an essential component of quality assurance in any domain of expertise, particularly where human life is at risk. Airline pilots, for example, must complete regular flight reviews under the watchful eyes of expert instructors to ensure ongoing competence. Yet, in medicine, we typically use initial training and certification as the beginning and end of direct, ongoing peer review. Yes, we have traditional CME courses, Maintenance of Certification programs, quality assurance processes, and review conferences—but none of these typically constitutes real-time peer review and reflection, arguably the most effective approach to adult learning. When is the last time that an attending EP (or any attending physician, for that matter) shadowed another attending physician during the course of clinic care? Shadowing to provide feedback is common in the military (the instructor in the “jump seat” during a flight) but virtually unheard of in everyday medical practice.

We know from the study of human performance across a variety of domains, however, that expertise requires maintenance and that knowledge and skill decay is a very real concern for a diverse group of practicing physicians. Some of us are classic academicians, with numerous layers of trainees surrounding us in our day-to-day practice, others work in environments where trainees are infrequently present or where patient age or demographic is relatively homogeneous, and still others have risen to administrative positions where our clinical experiences are becoming a much smaller portion of our work week. How do we keep ourselves clinically sharp?

Barriers and opportunities

  1. Top of page
  2. Rationale
  3. Barriers and opportunities
  4. simulation-based CME
  5. A Simulation network
  6. THE TRAINING SESSION
  7. Precedent and Potential
  8. References

What if EPs in practice could have access to direct and real-time peer review of their clinical performance? Clinical shadowing and feedback is one approach to such peer review (some training programs institute this evaluation approach for residents) but for attending staff, such an approach carries with it significant risk, both real and perceived, at deeply personal and professional levels. Who would set the standards, much less pay for the nonclinical time of the “evaluator,” if real-time shadowing were considered?

We think that simulation can help mitigate the inherent difficulties with scheduling and administering “live” real-time evaluation of EPs at the local level. But to even be considered, all potential risks must be overtly addressed and mitigated, such that physicians would want to participate and seek out opportunities to do so. We asked ourselves what such a system would entail and whether it would be sound and feasible.

simulation-based CME

  1. Top of page
  2. Rationale
  3. Barriers and opportunities
  4. simulation-based CME
  5. A Simulation network
  6. THE TRAINING SESSION
  7. Precedent and Potential
  8. References

We present an outline of a program that would provide practicing EPs an individualized opportunity to engage in a supportive training environment, to receive feedback, and to evaluate their own skills. Some skills will be those used in their daily practice; others will not have been performed since postgraduate training. This program would provide cognitive and procedural practice, as well as an opportunity to compare “comfort level” in discrete domains in comparison to an objective standard. It would provide tools for bridging gaps in performance and resources for continued training. The time spent would be supportive and collegial. All participants would by the end of the day have multiple opportunities to hone (or rehone) skills to proficiency, in any domain of competency.

A single training event, no matter how robust, cannot produce an expert; expertise takes substantial and deliberate practice.1 However, with practicing physicians, all of whom were at one time deemed competent by a rigorous standard, the task at hand is to refresh and revitalize skills and to reveal new techniques and protocols. The goals of simulation-based CME would be to provide practicing EPs with 1) opportunities to receive supportive feedback on simulation-based performance, based on objective standards; 2) opportunities to practice with newer techniques or devices sufficient to demonstrate competence; 3) a personalized review of the skills required to maintain competence; and 4) tools to continue practice at or near their home environment.

A Simulation network

  1. Top of page
  2. Rationale
  3. Barriers and opportunities
  4. simulation-based CME
  5. A Simulation network
  6. THE TRAINING SESSION
  7. Precedent and Potential
  8. References

Let us then propose, as a starting point, a half-day event. Practicing EPs would make arrangements to travel to an accredited simulation center of their choice. Eighty-five percent of EM residency programs nationwide already use full-body mannequin simulation,2 meaning that most academic EDs could become a training destination and part of a simulation-based CME “network.” It would be incumbent on an EM specialty group like the Society for Academic Emergency Medicine (SAEM), or a consortium of EM organizations, to organize the network and identify the criteria upon which a site and its instructors could be included. This would be similar to other simulation center certification programs sponsored by entities like the American College of Surgeons or the American Society of Anesthesiologists. While some academic EDs already have large simulation centers, accreditation to be a simulation-based CME site might require only a single simulation room. We recommend sufficient resources, expertise to conduct robust simulation scenarios, and faculty trained and qualified to provide meaningful feedback. Faculty development in the area could be incorporated into annual specialty or simulation meetings. Core instructor certification, for example, could be achieved in an expanded workshop at any one of several national venues that routinely attract academic faculty.

THE TRAINING SESSION

  1. Top of page
  2. Rationale
  3. Barriers and opportunities
  4. simulation-based CME
  5. A Simulation network
  6. THE TRAINING SESSION
  7. Precedent and Potential
  8. References

Before their visit to the appointed simulation site, EPs would have registered and responded to a series of questions designed to elicit information about their current practice pattern and their self-assessed comfort with the variety of procedures listed within the model of clinical practice. After orientation, the physicians would begin their session with a series of short calibrating clinical vignettes, including some procedural skills designed to determine what specific areas will require the most attention for each participant.

The simulation environment would be equipped with to provide an immersive experience on one or more “patient” presentations. As needed, the staff could include suitable standardized confederates (real or virtual through an overhead speaker) to simulate the complexity of human-to-human interactions with “staff” and “family members.” These calibrating vignettes would also clarify and establish the boundaries of the “fiction contract” required in simulation-based training. Faculty would provide feedback following a standardized approach, using objective performance data, in a psychologically supportive environment.

Participants will engage in multimodal training. Immersive training using standardized patient/high-fidelity simulation hybrids and procedural task trainers will be interspersed with constructive feedback and ratings of performance. These ratings will be designed to reveal the steps required to achieve “mastery” of the topic at hand.3 Subject matter will include common and less common clinical presentations.

A supportive environment will be essential, as no physician in practice would seek out personal or professional risk. Events will support reflection and self-assessment, encourage introspection and evaluation, and help all attendees achieve proficiency by providing suitable opportunities to practice and receive formative feedback. At the conclusion of the day, the physician will have been challenged and will have had successes and failures along the way, but in the end, will have achieved and documented proficiency. There will be some who require more time to achieve proficiency. For these, additional sessions or other learning modes may be necessary.

Precedent and Potential

  1. Top of page
  2. Rationale
  3. Barriers and opportunities
  4. simulation-based CME
  5. A Simulation network
  6. THE TRAINING SESSION
  7. Precedent and Potential
  8. References

The use of objective standardized clinical examinations as part of the oral board examination for EM residency graduates, along with the USMLE Clinical Skills Step 2 examination for medical students, has made the use of simulated case presentations a familiar venue for EPs. With 114 EM training programs currently equipped with functional mannequin-simulation capability,2 the potential size of an EM simulation network could facilitate easy access to CME sessions for thousands of practicing EPs each year.

Step 1: Define the Scope of the Program

The goal would be to define a program of useful practice and feedback opportunities grounded in the Model of Clinical Practice of EM4 and tailored to individual needs. The program would be voluntary and funded out of the individual’s CME budget. Each center would need accreditation to provide official CME credits. In some cases, participation could qualify the provider for an insurance discount program;5 and in the future, successful simulation CME programs might add value to board-level Maintenance of Certification processes (http://www.abms.org/Maintenance_of_Certification/). Such potential benefits could provide incentive to attend this venue over other CME opportunities. The setting would provide low-stakes opportunities for assessment, feedback, and practice-based improvement. Individual scoring and feedback would be completely confidential and would not be reported. The only enduring record would be of the curriculum and a certification of earnest participation.

Step 2: Prepare the Centers

The scenarios will require refinement and peer review. Existing relationships with the AAMC MedEdPORTAL (http://www.aamc.org/mededportal) and the SAEM Simulation Case Library (http://www.emedu.org/simlibrary) could be leveraged to achieve peer review acceptance of all scenarios employed. Hardware, such as the simulation devices and task trainers, would need to be selected and calibrated for use; again, most academic EM centers already have much of this infrastructure in place. Simulation operators and staff would require additional training tailored to the professional needs and sensitivities of practicing physicians. A standardized approach to debriefing would be required. Several academic centers have offered train-the-trainer debriefing workshops, and, as noted, additional training workshops could be developed and offered at long-standing annual meetings already frequented by intended trainees.

Step 3: Accredit Simulation Centers

The EM community could craft an accreditation process for the centers, based on several core elements, the foundation of which already exists at many EM residency programs. Simulation center leaders would be required to have experience in immersive simulation with practicing physicians. Centers with a patient safety and human factors focus would be desirable. Knowledge of the mastery learning model would be required, as would the ability of on-site staff to effectively present at least one high-fidelity simulation case in an ED setting. Multiple simultaneous cases are desirable to produce a reasonable degree of complexity, but a single mannequin-simulator might be sufficient for a small program that could also use actor-patients or table-top exercises to intensify the experience. These cases would be presented with a sufficient level of immersion such that an effective fiction contract is established. This would require presence of suitable simulation equipment and staff and knowledge of its best use and portrayal. A minimum square footage will be required with a suitable conference area, accommodations, and audio and video capabilities to allow review of training sessions.

Step 4: Leverage/Empower/Advantage the Stakeholders

It is critical to provide formative feedback without evoking embarrassment or shame. Educators must provide nonthreatening and impersonal judgment at the time of assessment and outline the path to achieve mastery. Some participating physicians may be comfortable with having local faculty colleagues serve as their peer reviewers; this would embody the highest standard of collegial trust and quality assurance. Other participants may wish to travel to neighboring institutions at varying distances from the home dynamic. In a model where academic EDs with simulation capability could comprise the core for the simulation network, staff could be drawn from the local simulation program. The program could be supported—or even generate income—by collecting CME tuition from participants. Participants may also benefit by qualifying for malpractice insurance discounts, or by using the experience to satisfy other specialty, hospital, or certification requirements. Documenting and maintaining a body of well-prepared EPs could be seen not only as a local hospital’s priority for excellence in care, but also as a national priority for emergency preparedness.

For any program like this to succeed, it must produce high-quality objective information and provide value to both the center and the participant. Networked simulation centers would be asked to pool deidentified data to overcome the limited study samples that have hampered simulation and education research to date. Such a platform would not only help us to advance the goals of continuous professional education, but also help us answer some of the very questions raised by the consensus conference itself.

The 2008 AEM Consensus Conference highlighted the potential for simulation-based training and evaluation to fundamentally enhance quality and safety in health care. In addition to core applications in EM training programs, we propose consideration of simulation-based CME for practicing EPs, leveraging the extensive network of EM-based simulation and training efforts. Simulation technologies will serve an important role in the maintenance of clinical expertise across specialties—and EM can help lead the way.

References

  1. Top of page
  2. Rationale
  3. Barriers and opportunities
  4. simulation-based CME
  5. A Simulation network
  6. THE TRAINING SESSION
  7. Precedent and Potential
  8. References