Hybrid Simulation…using patient actors to enhance simulation

I’ve gotten a bit behind in my posts mostly as I’ve just moved back from New Zealand but I’m hoping to get a few more regular posts. For those who’ve read this blog, you’ll know that I like to highlight innovative approaches to simulation. This post is mostly for those interested in medical simulation…hopefully providing some new ideas.

One of my interests is procedural skill acquisition and how simulation can be used to enhance learning. So when I came across this paper I thought it deserved mention. The authors, from the University of Toronto describe using “hybrid” simulation for teaching knee arthrocentesis among internal medicine residents. Residents went through a procedural skills curriculum where they received teaching and practice performing arthrocentesis. They had to interact with a standardized patient and explain risks/benefits of the procedure. Then they were evaluated on both technical & non-technical skills in a separate scenario. They demonstrated the feasibility of this approach and they showed high ratings of realism among trainees & standardized patients and it functions as a hypothesis generating study for if these acquired skills are translated to the clinical setting.

Great use of hybrid simulation for obstetrical scenario - live patient actor "giving birth". source: http://www.samuelmerritt.edu/hssc/task-trainers

Great use of hybrid simulation for obstetrical scenario – live patient actor “giving birth”. source: http://www.samuelmerritt.edu/hssc/task-trainers

Hybrid simulation is actually a pretty cool concept. For those are new to this, hybrid simulation combines patient interaction (using a standardized patient) with a bench model (or task trainer) that allows for procedural skill practice. The benefit of this technique is the learner gets to interact with a patient as if they’ll be the recipient of the procedure while also getting to master the technical skills of the procedure.

Using procedural competency as a goal in procedural training, hybrid simulation is an excellent method for integration into a training curriculum. In one definition of competency:

“it refers to a resident’s ability to safely prepare for, perform and navigate the complications of a procedure” (Mourad et al. J Gen Med 2010).

Hybrid simulation will allow the learner to manage each of these aspects. They practice how to prepare for the procedure (both technically and preparing the patient). This will include consenting the standardized patient to the risk and benefits. I think we often forget this key aspect and instead focus on the technical skill. Furthermore, hybrid simulation scenarios can also integrate complications and evaluate the learner as they manage both the technical and interpersonal issues that must be addressed.

Another group at the University of Ottawa has started using OSCEs as a method for evaluating procedural skills which also is quite innovative! I came across an abstract they recently presented and a quick google search revealed a manuscript that further outlines the integration of an OSCE for procedural skills. Definitely worth checking out.

In simulation, we spend thousands of dollars on advanced equipment that is designed to replicate real patient interaction. However, hybrid simulation shows us that we can enhance fidelity even more by using some imagination and combining a task trainer with a live actor.

Another example while I was in Auckland, I ran full trauma simulations with a live patient. At the helicopter base, we had an actor who had suffered a considerable trauma from a motor vehicle accident. Its very impressive to watch a team interact with a “real” patient compared to a manikin. There’s much greater concern with pain and emphasis towards communication of each management step – these are definitely lost during interaction with a manikin.

I think medical educators and those involved in curriculum design need to take the next step as we seek to improve procedural skill teaching in medicine – let’s start integrating live patient actors into our simulations. We’re starting to see that it’s feasible and that some considerable benefit can be ascertained. As we seek procedural competence, we cannot forgot the trainee should be evaluated for their ability to explain and work with a live patient throughout the procedure. Its not infrequent that trainees learn to perform a procedure but they have no idea the complication rate or even what can go wrong! Then when something does actually go wrong they haven’t thought about it. Integration of these  hybrid simulations will only enhance trainee skills and lead to improvements in patient safety – something we’re all working so hard to improve.

Information overload…staying up to date with new medical journal publications

As physicians, some of us love to read the latest journal publication while some of us don’t give a s@#!. Those in the latter category are more than happy to get the information at conferences or journal clubs in due time. There’s nothing wrong with these people…in fact, it could be argued this is a healthier approach than being addicted to your wireless device or computer waiting for the newest publication!

But for those of us who do get turned on by reading then talking about the newest publication the day it comes out “Epub ahead of print”, it can be a daunting task to stay up to date.

In our world where we’re exposed to up to the minute Twitter feeds, blog posts or push notifications, we can easily become overloaded and inundated with how to manage this information. The challenge is particularly difficult with journal publications. I admit, that I really enjoy reading the latest research data and while that doesn’t make me a bad person…it arguably makes me a less attentive husband (one woman’s opinion).

Are there any strategies for improving information intake and staying up to date with recent research? I don’t think this area is well taught in medical school or residency, partly due to the fact it’s a brand new method of information acquistion. Also, it’s rapidly changing with new sites and apps coming all the time.

I follow a few different journal topics including emergency medicine related, critical care, general medicine and medical education. Overall, this probably results in about 15-20 journals per month. I don’t read every article, nor do I read every abstract but I routinely read through table of contents or titles to make sure I’m staying up to date.

I’ve been thinking about this recently and while this post isn’t intended to be comprehensive, it does offer a few strategies that I’ve used to ensure I’m reading the newest evidence (any mention of a product/app below is only because I’ve found them helpful…I take no money from anyone). The following are in no particular order of preference. And if there’s an app or strategy I’m missing, please comment and I’ll add it to the post!

Here we go.

QxMD “Read”: I just started using this app and I really like it and I highly recommend it for any physician trying to keep up with the medical literature. And it’s FREE!  Anyways, it’s a Canadian company that “provides a single place to discover new research, read outstanding topic reviews and search PubMed“. It allows you to sign up through your library Proxy account and access PDFs for any medical journal that your library has available. If your university isn’t supported, email them, I believe they are really working hard to add new institutions. The key component for this app is the user can select which journals they want to receive regular updates from and easily access. Here’s a great review of the product.  For those using Android/non-Mac products I don’t think its available for any other platform than Apple (I only use Mac so I can’t confirm this).

Settings page for "Read"

Settings page for “Read”

Main interface used when reading articles

Main interface used when reading articles

Feedly: I also highly recommend this! and it syncs with GoogleReader which inexplicably is getting shut down. This program provides regular updates to any journal you wish to add to your list. The benefit to this approach is that it syncs well across platforms (both mobile and desktop) and it also houses all of your non-medical blogs and news sites. The difference between Feedly and QxMD is the latter offers a much easier route to read the PDF. Feedly simply provides you with the abstract then its up to you to figure out your own access method.

Screen Shot 2013-04-21 at 11.40.53 AM

Subscribe to a journal’s table of contents (TOC): Most journals allow you to provide your email so that every time a new volume is published, the TOC arrives in your inbox. This is how I started following journals though depending on the number of emails you receive (and the number of journals you follow), this process can easily overwhelm.

Example of "The Lancet" Table of Contents email

Example of “The Lancet” Table of Contents email

Subscribe to programs such as Journal Watch or InfoPOEMs (from Cdn Med Assoc): Essentially these organizations review the literature (typically 1-2 months behind) and send brief summaries of selected articles. This isn’t comprehensive and they’re not always free (e.g. Journal Watch) but it does help you find out about papers that maybe you wouldn’t have read. I use these methods then I download the article myself using my University library account. But it is a bit more labor intensive than Feedly or QxMD.

Follow an up to date medical blog. For those in emergency medicine/critical care, lifeinthefastlane.com is a must. The authors of this blog provide high quality, regular, up to date information about new publications that will interest EM physicians. Sign up to their LITFL review and they outline some of the newest journal articles out there. In addition, they link you up with all the most recent blog posts from around the EM world.

For those interested in medical education – I highly recommend a new blog “Medical Educator 2.0” that compiles medical education (and general education) related topics from sources around the world. Ali Jalali is a medical educator at the University of Ottawa (and happened to be a professor of mine in med school) and he puts together a very high quality site. If you subscribe then you’ll get regular emails when a new version/updates are posted.

Download each journal’s app: Great if you only read 1-2 journals but not sure how useful this is if you’re looking for regular updates from a broad range of journals. Here’s a list of journal apps for download.

Twitter: Either sign up and follow a journal’s twitter account (e.g. @EmergencyMedBMJ) or follow individuals that often retweet or post comments about new articles. This approach really maximizes the power of crowds and can make reviewing new articles much easier. On Twitter, you can also follow hasthtags like #meded and #FOAMed.

So those are a few strategies that I use. I welcome feedback and suggestions that I’ve missed. I’m happy to update this post with any ideas that you feel should be included.

Navigating the world of social media in clinical medicine

It’s great to see articles now about the impact and effects of social media in medicine especially in other specialities. This article titled “Social Media and Clinical Care” was just published in Circulation and deserves at least a brief review by any clinician who uses social media either to augment clinical care. It’s also encouraging to see this appear in the journal Circulation which has as a relatively high impact factor (around 14). Clearly the academic medical community and more importantly the general medical community is taking note of the importance of social media.

Whether you like it or hate it, I would argue we shouldn’t fight social media. It’s unlikely to disappear especially now with more than 1 billion smartphones on the planet.  Instead as clinicians we should use it in a way that helps us communicate with each other, with patients and ultimately improves care. That being said, social media does NOT equal good or better! (it can be ). We always strive to “do no harm” and social media in medicine should be no exception.

To borrow the Spiderman quote “with great power comes great responsibility“. The same applies to social media…in fact maybe I should try and coin my own modification “with great social media power comes great social media responsibility”! But as we increasginly engage in social media we must recognize it’s power…which is why we should continue to use it but also understand how it can be quite dangerous.

What this article does it outline the various ways that it can be used within clinical medicine. It also highlights the ethical challenges we face and provide some perspective using an ethical framework.  The great thing is that in the spirit of FOAM (free open access medicine) this article is free! Congratulations for Circulation for making this accessible to all.

Who should read this article?

  • Any clinician who has patients participating in social media as a source for medical advice
  • Any clinician who uses social media as a form of communication/education with other clinicians
  • Any clinician who engages with their patients through social media as a form of education
  • Any clinician looking for some good references of studies that evaluate the impact of social media within medicine/patients

Does this sound like all clinicians should read it? I would say unless you still think rotating tourniquets is the optimal method to treat heart failure, yes…you probably should at least give it a glance.

What I found interesting was the discussion about whether it’s appropriate to use specific patient cases on a blog. I haven’t taken up this practice, but I really do value reading other medical blogs when authors recount specific instances. It’s helpful to read these accounts – almost as if you’re speaking with a colleague about an interesting/challenging case…but now your colleague can be anyone in the world. Powerful stuff! But at the same time, I respect the issues of confidentiality that surround such discussions. What was interesting was the article quoted data that found

“medical educators…felt that writing a deidentified patient narrative using a respectful tone was never or rarely acceptable (61%)”

That is really quite high…61%! And impressively it was a “deidentified” patient described  using a “respectful tone”. I’m curious to know what others think but I personally don’t have a problem with it. I think it’s obviously better to have patient consent but what if the case was 2 years prior? Does that change anything? Pragmatically it would be hard to find that patient…and perhaps considerable learning can be achieved from the case. This is definitely a challenge for educators/clinicians in balancing the risks & benefits. More importantly, it doesn’t seem like our colleagues may support such actions!

The authors of this article outline some recommendations for physicians who have blogs/websites as well as those who engage in online social networks. None of these are revolutionary but they provide us with good reminders of how we can continue to uphold our commitment to improving patient care in an ethical manner.

Source: Chretien & Kind Circulation 2013

Source: Chretien & Kind Circulation 2013


Source: Chretien & Kind Circulation 2013

Source: Chretien & Kind Circulation 2013



A reflection on SMACC (Social Media and Critical Care Conference) in Sydney!

The past 3 days has been a whirlwind experience in Sydney, Australia where I attended the Social Media and Critical Care Conference (@smacc2013).


I joined a group of several of my colleagues at Auckland HEMS to participate in the inaugural conference. It combined two seemingly unrelated things – social media & critical care. Making it probably the among the first (if not the first) medical conference to have social media as a key theme. Over the past few years, physicians in critical care, emergency medicine and prehospital medicine have become leaders in social media and using the internet as a learning tool. The creators of the conference started the innovative website Lifeinthefastlane which is a blog read by thousands of acute care physicians around the world. They decided to extend their scope and create a conference which in my opinion was a huge success! This conference was a natural extension of the relatively new concept that highlights “medical education for anyone anytime, anywhere” – this concept is known as FOAM or “free access open meducation” (#FOAMed on twitter). I won’t describe it fully here as others have already done so. But it’s the way in which we use social media and the internet to share, disseminate and collaborate within medical education.

As a reflection on the conference I’d like to share a couple highlights and concepts that emerged. What was unique about the conference was the use of Twitter. There was heavy emphasis on live tweeting during each session with a designated twitter coordinator who would pose questions to the speakers directly from those asked on Twitter. There was constant discussion on Twitter with both conference attendees and even those clinicians half-way around the world. Let me provide a brilliant demonstration of this in action. In one session about coagulation in trauma, the session facilitator (Dr. Minh Le Cong from the blog PHARM) tweeted asking for comments from those in the twittersphere. Within minutes there were comments coming in from Dr. Karim Brohi, a trauma surgeon in London, England who is a world expert in coagulation in trauma. A discussion among the speaker and the audience resulted based on his comments. Never before had I seen such interaction at a global level occur during a conference. The power in capturing ideas and facilitiating live discussion among both those attending the conference and leading experts sitting in a room across the world is amazing!

When I would look around the room in each session, there was a barrage of tweeting with many sending out comments made by conference speakers as they happened. This is incredibly powerful. It allowed for an immediate online commentary for those not attending the conference. But it also allowed those of us in other sessions to hear some highlights and really get an idea of what was happening especially if there were controversial topics being discussed.

Every talk was videorecorded and posted online for free viewing by anyone in the world. This represents a huge step in promoting free open access medial education (FOAM). Why we restrict education to those who can afford or arrange travel to these conferences is mindboggling. Our business is to improve patient care and if we can collaborate and share ideas that emerge from great meetings like this then our patients will definitely benefit.

Imagine a speaker says something quite controversial. Previously it might never really be discussed again. Or perhaps it might be misrepresented several weeks or months later in a report. At this conference, speaker comments could be disseminated rapidly with the opportunity for rapid responses and discussion.

Unlike many academic conferences, speakers were introduced based on their blog (and not their publication count or number of academic achievements). While the merits of publications should not be diminished, it highlighted that an online presence where your ideas are shared, exposed and subject to review from people around the world is a new way to gain status within the medical world.

Finally, the conference started to address how FOAM, social media and asynchronous learning can be incorporated within medicine. There were enthusiastic talks that demonstrated the power of online education but also some excellent perspectives that online learning is not a learning panacea. These sessions were humbling since we must remember that despite all this technology, we still treat people. Our job requires human interaction and without reflection we can begin to forget this. Those on blogs and twitter drive the curriculum because topics are interesting, but sometimes the less sexy topics deserve discussion. There’s no curriculum to guide us online and this may not always benefit learners.

As long as we can appreciate these limitations we can maximize the potential of a asynchronous learning using an online platform. Never before can we collaborate, share, discuss and even criticize. It’s an exciting time for medical education and SMACC did a great job making it a reality!

Should the simulated patient die? Pros and cons to acting as the grim reaper

This post discusses a great article about death in simulation and the impact on learning. I’ve learned about the importance of this topic from @jameslhuffman, an ED physician with an interest in simulation. For those interested/involved in simulation, its importance is understated but probably moving forward we’ll hear more about.  I highly recommend that anyone who is regularly running simulations or involved in medical simulation check out this paper. I’ll review some of the highlights below.  This article follows the same topic that I wrote about a few weeks ago regarding the ethics (or impact of being unethical) of medical simulation.

Important to decide how much of a grim reaper you should be as a simulation facilitator

Important to decide how much of a grim reaper you should be as a simulation facilitator

The authors reviewed the literature for evidence about the impact of death during simulation and how it affects learners. I won’t discuss their methods as I really don’t think that’s the important message of the paper – it should be noted it’s simply a literature review rather than anything more detailed or comprehensive (e.g. systematic review or meta-analysis).

Who cares whether the simulated patient dies? Why does this even matter? These are two very reasonable questions and hopefully this review will help to shed some light on why some consideration should be made about the impact of the simulated patient’s life expectancy during the scenario!

The authors outline a few concerns that have been described regarding simulated death:

  • Stressful situations including death may negatively affect learning and memory, as a result the scenario may not achieve its predefined learning objectives
  • Death during simulation may instill negative feelings among learners about simulation (e.g. “every time I do a simulation, the patient dies…I don’t ever want to participate in that again!”)
  • Death of a simulated patient may overtake the other objectives of the scenario and may occupy most of the debriefing 
  • Inability to maintain an environment of psychological safety – learners lose trust in the instructors if too many unexpected and difficult situations occur thus detracting from learning

I think all of these are very reasonable concerns and should be considered when designing a simulation scenario however, I don’t believe (nor do the authors of this review) that death in simulation should be abandoned. It clearly has a role as death in real life is inevitable and we should train and practice how to manage it. In addition, trainees must be exposed to scenarios where regardless of the therapies implemented the patient will inevitably die. This happens almost every day for clinicians involved in acute care medicine.

What I liked about this review is that the authors included some recommendations for educators to consider when designing a scenario.

First, they defined 3 types of simulated death:

  1. Death expected by both the facilitator & the learner – include discussion about end-of-life
  2. Death expected by the facilitator & unexpected learner – may include a planned respiratory arrest that the learner must attempt to manage
  3. Death unexpected by facilitator & the learner – this involves the learner administering a fatal drug or failing to recognize a fatal condition

Depending on what type of death occurs may dictate the implications for debriefing. The following are recommendations that the authors make based on a combination of evidence and experience but in general, they’re quite reasonable. In planning for a death during simulation here are some considerations:

  • Ensure the instructor is prepared for the discussion
  • Ensure the participants have a pre-briefing session that includes mention of the possibility that the simulated patient may die 
  • Simulated death should probably not be used with novice learners
  • Scenarios for advanced learners should include simulated death if clinically appropriate
  • Simulated death shouldn’t be used for punishment (e.g. death shouldn’t occur if a participant administers a noncritical drug) – death should only occur when the learner’s actions lead to a life-threatening consequence in real-life
  • A de-briefing after a simulated death is essential – it must safely address the factors  that led to the patient death with discussion about team dynamics & medical management
  • Acknowledge participant emotions associated with death 

In my opinion, most important however is simply to acknowledge that death during simulation isn’t without consequences. The impact on learners is relatively unknown given the lack of evidence. But we should consider how much stress we place on the learners as it may positively or negatively impact their learning.

Hopefully these considerations will be helpful in evaluating the sim patient’s life expectancy! I found it extremely useful and I acknowledge that the paper is better than any summary I can provide. Here’s the reference below for the article

Simul Healthc. 2013 Feb;8(1):8-12. doi: 10.1097/SIH.0b013e3182689aff. To die or not to die? A review of simulated death. Corvetto MA, Taekman JM. 

Cricothyroidotomy – considerations for teaching & simulation

Earlier this week I posted about the integration of a cric task-trainer at ARHT. I’ve decided to follow this up with some general evidence about cricothyroidotomy training.

The data regarding technique selection for cricothyroidotomy exists primarily in the context of simulation. It would be impossible to run a trial to compare techniques in real patients given the rarity of the scenario. In general, there are two types of techniques: 1) open or surgical cricothyroidotomy 2) percutaneous or needle cricothyroidotomy. I tend to favor an open technique (and maybe with a bougie)  given the simplicity but there is some evidence to support the needle method. There is a nice  Below is a brief outline of some evidence-based considerations for anyone involved in training clinicians for cric performance.

Needle vs. Open

  • Randomized trial of emergency physicians performing surgical and percutaneous cricothyroidotomy on cadavers. Time to first ventilation was significantly longer using the surgical technique (108 seconds vs. 136 seconds) while there were significantly more injuries to surrounding structures using the open technique (6 thyroid vessel injuries vs. none)
  • Authors concluded results tend to favor percutaneous technique
  • I’m quite surprised that time was shorter with the percutaneous technique – interesting result!

Alternative techniques

Time to Completion 

  • Highly dependent on when the timer starts but regardless everyone agrees time is important! And less is more!
  • 40 seconds was achievable in one study – time to skin palpation to first ventilation when all equipment was laid out
  • 95 seconds (mean) was recorded in another study as time from first grasping cric equipment to first ventilation

Number of times to achieve competence

  • Debatable whether experience = competence
  • Performance times plateau after 4 attempts (using a manikin)
  • Very little evidence to support number of times needed especially since all evidence is manikins or cadavers

Room for improvement as an inter-disciplinary approach

  • Several studies show that often it’s the surgeon performing cricothyroidotomies in emergent settings (article 1, article 2
  • This has important training implications – we should be training as a trauma team and incorporating the trauma team during in-situ simulation
  • EM teachers & educators must also be aware of this issue and work with surgeons so that they understand cricothyroidotomy is completely within the scope of practice for EM physicians (or anyone who performs RSI)

Some High Quality Learning (FOAMed)

Cricothyroidotomy training for the pre-hospital setting


Newest addition to the ARHT simulation centre. Cricothyroidotomy task trainers built from old manikins. Rolled them out successfully last week with our paramedics using them for the first training session.

One of my medical education interests is looking at how we train and practice rarely performed procedures. For these situations, simulation offers an excellent method of training. The challenge, however, is recreating the fidelity of such situations since many rarely performed procedures are quite invasive.  Often we’ll start the training with a task-trainer like model and then progress to a full size manikin. Task-trainers are simulation models specifically designed for one type of procedure. 

In emergency and pre-hospital medicine, the cricothyroidotomy is among the most invasive, time critical yet rarely performed procedures. In addition to the potential technical challenges of this procedure, the decision to perform a cric might be even more difficult.  Identifying a “can’t intubate, can’t ventilate” scenario and then to “pull the trigger” may be one of the hardest cognitive leaps we face in resuscitation.  For example, last week, in the  Auckland emergency department we ran an in-situ simulation scenario for the registrars that required the performance of a cricothyroidotomy. The goal of the simulation was only to perform a cric…in fact, we even gave the registrar team a heads up that the patient would required a cric. Amazingly while we only used a task trainer that didn’t even allow for intubation, the trainees still tried to proceed with intubation. There was considerable reluctance to finally acknowledge that it was a “can’t intubate, can’t ventilate” situation.  I don’t think we train enough to practice taking that cognitive leap to the final step in the failed airway algorithm. Even this short little scenario provided evidence that such scenarios require practice and should be simulated.

This past week at the base we rolled out our cricothyroidotomy task trainers. We constructed our trainers based on a model created by Agnes Ryzynski & Dr. Jordan Tarshis at Sunnybrook Health Sciences Centre. They described the creation of such task trainers using old/broken manikin heads and some innovation using easily found products within the hospital. The value of such a trainer extends beyond its simplicity as it also  maintains good fidelity, it costs less than $30 to make and it recycles old manikin heads! 
Such a trainer might supplement an even lower fidelity construction depending on the setting. At the ARHT, our go-to method for cricothyroidotomy is a bougie-assisted technique which is described in this article and video. We’ve selected this technique based on simplicity in the field and relatively minimal equipment required. But there’s good debate out there whether these should be performed using the needle or surgical approach. Scott Orman (ED physician and blog author for aucklandhems.com) wrote about the topic last week with some great links.

You can see from the pictures, that the paramedics have set up on the left side of the patient. We were trying out different approaches and set ups to find out what works best. Personally, I prefer the right side of the patient. In our setting within the helicopter  we only have access to the patient’s right side. As a result, there may be some benefit to be on the right side. The ergonomics of such a high stakes procedure are probably understated so training in the same way that you’ll perform the procedure is essential. I acknowledge that you might need to be a bit flexible regarding setup but in general, the airway team should be well prepared and anticipate where equipment and personnel will be placed.

Here’s a few more pictures of our training day.










Next post will have a bit more about the evidence base around cric performance.


Deception and misdirection – Is being “unethical” a bad thing during medical simulation?

This week’s post was prompted from a recent set of articles in the journal Simulation in Healthcare. Until recently, I’ve given little thought to purposeful deception during  simulation scenarios. Often scenarios are designed to be somewhat “tricky” with a key learning point. This often takes place by incorporating a random medical fact/concept that the learner may not pick up. For example, the seizing patient in refractory status epilepticus…if the participants took a proper history from the family they would have found out that patient has recently started treatment for tuberculosis. The diagnosis of INH induced seizures would be clinched  But what about when you purposefully try to mess with the participants and actually challenge their personality, their ability to behave as a physician and arguably break the psychological safety that should exist within a simulation? Is this beneficial or does such a scenario inhibit learning? optical-illusion-man

I’d like to review and comment on the articles and editorials published in the most recent edition Simulation in Healthcare. The article is a description about how simulation was used to test/study medical hierarchy during a medical resuscitation.

The authors (pediatric intensivists) implemented a scenario where a young child was critically ill with hyperkalemia resulting in a dysrhythmia and incidental hypophosphatemia. The team leader (who was a confederate) was scripted to order potassium phosphate to replace the low phosphate, however, this would also result in death of the simulated patient. The learners (ICU residents/fellows) had some idea that a team leader (staff intensivist) would appear part way through the case but were unaware that such hierarchy conflict would emerge. The team leader confederate was instructed to comply by not administering the drug only if the team demonstrated repeated or sustained challenges in giving this potentially deadly medication. The authors describe running the scenario 3 times and reported the following responses:

  1. Appropriate, successful challenge of drug administration and team leader complied
  2. Appropriate challenge but delayed resulting in delayed appropriate management
  3. The order was not challenged and the simulated patient died

What are you thoughts after reading this? Do you have a visceral reaction that this was a good or bad idea?

My opinion is that in the right circumstances with trained educators I think this is extremely powerful, useful and should be part of the educational toolbox. There’s an accompanying editorial where the authors have raise multiple concerns about this approach which I won’t reiterate – all of which are valid. Though interestingly they also provide well written counter arguments in anticipation of how others may respond.

Simulation scenarios that address non-medical aspects that can lead to patient harm should be simulated. While I agree that this type of case probably is best administered by an experienced simulation educator with highly skilled participants, I disagree with the editorial which suggests that such scenarios should be avoided. They were concerned that this may cause the participant to think:

“Am I the kind of person who is unwilling or unable to challenge a respected colleague who I think is making bad medical judgments, even when this may result in serious injury to the patient, or even death”

I would argue (like the study’s authors) that with proper briefing regarding the educational purpose of the simulation and adequate de-briefing to explore the cognitive decision points that resulted in the patient’s outcome, then learning can be achieved. The degree of deception should be related to experience level of the participants since junior learners would unlikely benefit from such a difficult scenario. However, increasingly, we recognize that teamwork and crew resource management (CRM) play an important role in how we care for patients. Our non-technical skills and awareness to our own cognitive biases during critical situations has considerable impact on patient outcomes.  It’s inevitable that during critical situations we may face challenging interpersonal interactions or difficult decisions.  We should train by pushing the limits of the team and the system. I acknowledge there are some who are concerned regarding the disregard for psychological safety during such simulations. I argue that with proper approaches that psychological safety can be managed. Furthermore we can do a much better job controlling the psychological safety of a simulation than we can simply leaving learners to fend for themselves during a real-life situation where not only their psychological safety is at stake, but the medical safety of the patient is at risk.

The argument that we should study this more before widespread use is reasonable but I’m not sure that results from one centre will be applicable to others. The validity of such studies remains challenging to say the least. Certainly larger studies will help, but meanwhile simulations including misdirections or deceptions that challenge not only technical knowledge but interpersonal and team dynamics should be supported.


Abstract from cited article above 

Case & Commentary: Using Simulation to Address Hierarchy Issues During Medical Crises. Calhoun AW et al. Simul Healthc. 2013; 8(1):13-19

Medicine is hierarchical, and both positive and negative effects of this can be exposed and magnified during a crisis. Ideally, hierarchies function in an orderly manner, but when an inappropriate directive is given, the results can be disastrous unless team members are empowered to challenge the order. This article describes a case that uses misdirection and the possibility of simulated ‘‘death’’ to facilitate learning among experienced clinicians about the potentially deadly effects of an unchallenged, inappropriate order. The design of this case, however, raises additional questions regarding both ethics and psychological safety. The ethical concerns that surround the use of misdirection in simulation and the psychological ramifications of incorporating patient death in this context are explored in the commentary. We conclude with a discussion of debriefing strategies that can be used to promote psychological safety during potentially emotionally charged simulations and possible directions for future research. (Sim Healthcare 8:13Y19, 2013)