Emergency Medicine

Emergency medicine consensus conference examines the role of health care simulation in developing clinical expertise

Simulation of medical procedures is one way to develop and improve clinical expertise. In fact, a bill is now before Congress that is designed to enhance Federal support of medical simulation initiatives nationwide. In May 2008, a conference was held in Washington, D.C., to help define future directions in simulation-based research in emergency medicine and across health care.

The November 2008 issue of Academic Emergency Medicine 15(11) published proceedings of the 2008 Academic Emergency Medicine Consensus Conference, "The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise," which was partially supported by the Agency for Healthcare Research and Quality (HS17656).

The journal is available online at www3.interscience.wiley.com/journal/121498292/issue. A limited number of copies of the journal (AHRQ Publication No. OM-09-0021) are also available from the AHRQ Publications Clearinghouse.

The special issue was edited by Amy Kaji, M.D., Ph.D., of Harbor-University of California Los Angeles Medical Center, and David C. Cone, M.D., of Yale University. The structure of the conference is outlined by the conference co-chairs, James A. Gordon, M.D. M.P.A., of Massachusetts General Hospital, and John A. Vozenilek, M.D., of Northwestern University, in the first paper of the issue, which carries the conference title. They describe the four conference consensus discussion groups, which examined individual/cognitive expertise (global provider competency), group expertise (effective teamwork and communication), technical expertise (procedural and surgical skill), and systems expertise (effective simulation at the organizational level). Following is a brief summary of the proceeding papers included in this special issue.

Vozenilek, J.A., and Gordon, J.A., "Future directions: A simulation-based continuing medical education network in emergency medicine," pp. 978-981.

In this paper, the conference co-chairs assert that emergency medicine is uniquely positioned to pioneer simulation-based training as one component of ongoing continuing medical education (CME). They outline a program for a simulation-based CME network in emergency medicine that would provide practicing emergency physicians with an individualized opportunity to engage in a supportive training environment, to receive feedback, and to evaluate their own skills.

Weiss, K.B., "Introductory remarks by the president of the American Board of Medical Specialties," pp. 982-983.

The author notes the rapidly growing interest among numerous medical specialty boards in using simulation for physician training. He asserts that the science of simulation will need to demonstrate the validity and reliability of these techniques and demonstrate how competency using simulation relates to clinical outcomes. Also, simulation tools and techniques will need to be built that can be easily adopted and scalable to large numbers of users at a reasonable cost.

Ericsson, K.A., "Deliberate practice and acquisition of expert performance: A general overview," pp. 988-994.

Expert performance can be traced to active engagement in deliberate practice (DP), where training is focused on improving particular tasks. DP also involves provision of immediate feedback, time for problem solving and evaluation, and opportunities for repeated performance to refine behavior. In this paper, the author draws upon the principles of DP established in other fields such as sports to provide insight into developing expert performance in medicine.

McGaghie, W.C., "Research opportunities in simulation-based medical education using deliberate practice," pp. 995-1001.

This article describes six lessons about simulation-based medical education (SBME) using DP and the mastery learning model. For example, DP helps engage learners with a well-defined learning task at an appropriate level of difficulty. It also provides focused repetitive practice and allows trainees to monitor their learning experiences and correct errors. The mastery learning model provides a minimum passing standard of mastery and continued practice until that standard is reached.

Salas, E., DiazGranados, D., Weaver, S.J., and King, H., "Does team training work? Principles for health care," pp. 1002-1009.

The authors analyzed studies on team training specific to health care and identified eight key principles for effective team training. These included identifying critical teamwork competencies; emphasizing teamwork over task work; ensuring simulation training relevance to the transfer environment; evaluating clinical outcomes, learning, and behaviors on the job; and reinforcing desired teamwork behaviors, for example, through coaching and performance evaluation.

Rudolph, J.W., Simon, R., Raemer, D.B., and Eppich, W.J., "Debriefing as formative assessment: Closing performance gaps in medical education," pp. 1010-1016.

These authors describe a four-step model they propose for postsimulation debriefings, which can also be applied to bedside teaching in the emergency department (ED) and other clinical settings. The steps are to note salient performance gaps related to predetermined objectives; provide feedback describing the gap; investigate the bases for the gap by examining the frames and emotions contributing to the current performance level; and close the performance gap through discussion or targeted instruction on principles and skills relevant to performance.

Fernandez, R., Vozenilek, J.A., Hegarty, C.B., and others, "Developing expert medical teams: Toward an evidence-based approach," pp. 1025-1036.

These authors recommend further research on developing expert emergency medical teams in six key areas. The first three areas are developing and refining core competencies for emergency medicine teams; leadership training for emergency physicians; and conducting comprehensive needs analysis at the organizational, personnel, and task levels. The second three areas are development of training platforms to maximize knowledge transfer; debriefing and provision of feedback; and proper implementation of simulation technology.

Bond, W., Kuhn, G., Binstadt, E., and others, "The use of simulation in the development of individual cognitive expertise in emergency medicine," pp. 1037-1045.

The authors of this paper discuss the use of medical simulation for the development of individual expertise in emergency medicine. They examine such issues as whether simulation can be combined with other strategies (like interviews) to effectively identify expert behavior; the influence of simulation on the learning curve; and the optimal teaching strategy for simulation cases. They note that collaboration between medicine, cognitive psychology, and educational academic communities will be needed to answer these questions.

Wang, E.E., Quinones, J., Fitch, M.T., and others, "Developing technical expertise in emergency medicine-the role of simulation in procedural skill acquisition," pp. 1046-1057.

The emergency physician has to perform a diverse array of procedures, including airway management, minor surgery, orthopedic manipulation, and team management. The authors of this paper reviewed simulation studies on procedures germane to emergency medicine training, virtual reality training, and instructional learning theory as it pertains to procedural skill acquisition and skills decay. They discuss the role of simulation in teaching technical expertise, identify training conditions that lead to effective learning, and recommend future research.

Boulet, J.R., "Summative assessment in medicine: The promise of simulation for high-stakes evaluation," pp. 1017-1024.

In the past 10 years, simulations have been successfully incorporated in a number of high-stakes physician certification and licensure exams. As simulation technology expands, this groundbreaking work can serve as a basis for organizations to build or expand their summative assessment activities. The author concludes that simulation, whether it involves standardized patients, computerized case management scenarios, part-task trainers, electromechanical mannequins, or a combination of these methods, holds great promise for high-stakes assessment.

Kobayashi, L., Overly, F.L., Fairbanks, R.J., and others, "Advanced medical simulation applications for emergency medicine microsystems evaluation and training," pp. 1058-1070.

These authors evaluated the best applications of simulation techniques and technologies to small-scale systems in emergency medicine. They describe relevant theories and terminology for discussion of health care systems and medical simulation. The authors also review prior and ongoing efforts in medical simulation programs. In addition, they develop a framework for discussing systems thinking for emergency medicine and explore the application of advanced medical simulation methods to a defined framework of emergency medicine microsystems to promote a "quality-by-design" approach.

Spillane, L., Hayden, E., Fernandez, R., and others, "The assessment of individual cognitive expertise and clinical competency: A research agenda," pp. 1071-1078.

This group asked five questions critical to simulation-based assessment (SBA) of emergency physicians: What cognitive skills/core competencies are crucial to the competent practice of emergency medicine that should be assessed using mannequins or other types of simulation? Are all types of simulation technology suitable for physician assessment? What are the characteristics of a "criterion standard" measurement tool? Do better outcomes in the simulated environment predict better outcomes for real patients? Finally, how often should practicing physicians be evaluated, and does SBA have a role in continuing assessment and credentialing for practicing physicians?

Lammers, R.L., Davenport, M., Korley, F., and others, "Teaching and assessing procedural skills using simulation: Metrics and methodology," pp. 1079-1087.

Teaching and testing technical skills require methods and assessment instruments that are different than those used for cognitive or team skills. Based on work published in other medical disciplines and education, behavioral, and human factors research, these authors explored questions in six research areas. These included measurement of procedural skills; development of performance standards; assessment and validation of training methods, simulator models, and assessment tools; optimization of training methods; transfer of skills learned on simulator models to patients; and prevention of skill decay over time.

Shapiro, M.J., Gardner, R., Godwin, S.A., and others, "Defining team performance for simulation-based training: Methodology, metrics, and opportunities for emergency medicine," pp. 1088-1097.

About 40 percent of emergency department lawsuits involve teamwork errors that could have been mitigated or prevented. To assist emergency medicine and health care in the design and delivery of simulation-based training (SBT) for training and evaluating teamwork, these authors propose a scientifically based method for SBT design and evaluation. They review existing team performance metrics in health care along with recommendations. Finally, they focus on leadership as a target for SBT, because it has a high likelihood of improving many team processes and ultimately performance.

Kaji, A.H., Bair, A., Okuda, Y, and others, "Defining systems expertise: Effective simulation at the organizational level-implications for patient safety, disaster surge capacity, and facilitating the systems interface," pp. 1098-1103.

The authors of this paper combined an online discussion group of emergency physicians, an extensive review of the literature, and a public hearing of questions at the consensus conference to identify six key research questions that would inform understanding of simulation's impact at the organizational level. For example, they recommend research areas they believe will improve understanding of how simulation affects patient safety, disaster surge capacity, and intersystem and interagency communication.

Fernandez, R., Kozlowski, S.W., Shapiro, M.J., and Salas, E., "Toward a definition of teamwork in emergency medicine," pp. 1104-1112.

Simulation has been used within aviation, the military, and now health care to effectively teach and assess teamwork skills. These authors identify evidence-based recommendations for an emergency medicine team taxonomy and performance model. They present a well-defined, well-described taxonomy that will help guide design, implementation, and assessment of simulation-based team training programs in health care.

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