Simulation Coming to the Forefront in Anesthesia Training

Tammy R. Carpenter, M.D.

SA recently surveyed senior residents in anesthesiology programs across the country about their experiences with simulation. Three-quarters of those responding had received simulation-based training during their residency with an equal number finding the instruction valuable. The majority of respondents indicated that they would seek simulation-based continuing medical education (CME) after graduation, and they also were prepared to pay more for it.

Simulation appears to offer much to educators. Simulation-based learning is an active, rather than passive, learning process. In the simulation environment, mistakes can be made in a nonjudgmental atmosphere without risk to a patient’s safety. Clinical scenarios can be analyzed and repeated until mastery occurs. Standardized scenarios with exact causal mechanisms can be presented with explicit feedback provided to the learner.

Moreover unusual clinical situations such as airway emergencies and cardiac arrest can be encountered frequently and at convenient times for the learner. Technically challenging procedures, such as central line placement and regional anesthesia, can be practiced and mastered without supervision or patient harm. Simulation also can be used to replicate human physiology and its response to interventions. It can provide a laboratory for medical students rotating through anesthesiology or residents in other specialties acquiring airway skills.

Traditionally simulation education in anesthesiology has been limited to training programs at medical schools and teaching hospitals. As a result, many anesthesiologists in clinical practice have not yet experienced this valuable training experience. In order to introduce ASA members to simulation education, ASA, in cooperation with simulator centers around the country, has developed a “Simulator Saturday” that occurred for the first time last year on March 11.

ASA has surveyed members about their experiences with and attitudes toward simulation. One-fourth of respondents had participated in simulation-based CME while about 80 percent thought simulation-based CME programs offered benefits over traditional lecture-based CME, and the same number was interested in participating in simulation. Nearly 90 percent of respondents were interested in using simulation to “practice” uncommon, difficult situations (difficult airway, anaphylaxis, cardiac arrest, malignant hyperthermia), and 80 percent wanted to rehearse crisis resource management. Three-quarters of respondents would participate in CME at least once every two to three years, but only 20 percent would be willing to pay more than the cost of a lecture-based CME course unless it was weighted (more than one credit hour per hour attended).
Traditionally accreditation is based on the results of written and oral examination. These evaluate the first two stages of Miller’s model of medical competence, “knows” and “knows how.” The next two stages of competence are “shows how” and “does.” Simulation-based obstructive structured clinical examinations (OSCEs) can assess the “shows how” level of competence.

The role of simulation for accreditation has been limited to date. The New York State Society of Anesthesiologists requires it for regaining accreditation after licenses have lapsed. First-year anesthesiology residents in Rochester are required to pass a simulation session prior to taking overnight call. The University of Pittsburgh requires simulation-based training for difficult airway management.

In 2003, the Israeli Board of Anesthesiology began requiring simulation-based OSCEs prior to certification. The majority of examinees have found the difficulty level to be reasonable and prefer simulation-based examination over traditional oral examination. The scenarios were designed to provide clinical situations that residents near the end of their training are required to handle competently as defined by expert opinion. Below is an example of a simulation scenario used by the research team in Israel:

Anaphylactic Reaction
A few minutes after tracheal intubation, the surgeon requests the administration of an antibiotic. At the same time, the anesthesiology resident administers a muscle relaxant for surgical relaxation. An anaphylactic reaction is triggered, with an increase in heart rate to 120 bpm and a decrease in systolic blood pressure to 50-60 mmHg, refractory to treatment with ephedrine and phenylephrine. The participant is informed that a rash is present, if he or she inquires. The participant is given 15 minutes to diagnose and treat the anaphylactic reaction, and grading is focused mainly on making the correct diagnosis and appropriate and timely administration of I.V. fluids and epinephrine.

The American Board of Anesthesiology does not currently require simulation-based examinations for board certification. There are thoughts that they may be included as a part of Maintenance of Certification in Anesthesiology in the future.

It is not surprising that trainees readily accept new technology. It is refreshing that so many practicing anesthesiologists also recognize the value of simulation. And, like it or not, those of us required to be recertified will likely encounter simulation for maintenance of certification in the future.

Tammy R. Carpenter, M.D., is a CA-3 resident at Oregon Health Sciences University, Portland, Oregon.