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Clin Exp Emerg Med > Volume 11(2); 2024 > Article
Hock, Cassara, Aghera, Saloum, and Bentley: Attending physicians as simulation learners: summary of current practices and barriers in emergency medicine
Simulation-based education (SBE) has successfully improved patient safety and care quality through training and assessment of individuals, teams, and health care systems [15]. Simulation has been shown to be an effective modality of teaching for a wide range of participants, across a variety of domains ranging from procedural skills to communication techniques and team training [4]. Emergency medicine (EM) continues to be a leader in simulation, with most simulation efforts focused on graduate medical education. Less emphasis has been placed on attending EM physician continuing education through simulation, but a recent survey demonstrates a specific need for development in this area [6].
Continuous medical advances make it important for physicians at all career stages to stay up to date. This challenge is compounded in EM because of the broad scope of the specialty and the performance of high-acuity, low-frequency procedures. Lifelong learning in the form of continuing medical education (CME) has been encouraged or mandated by hospitals, credentialing bodies’ ongoing professional practice evaluations and medical boards’ maintenance of certification (MOC) requirements to help providers stay up to date with current practice. Though much of the content offered is lecture-based and passive, SBE programs for faculty have been developed and overall well-received [79]. Prior reviews have found that CME and MOC activities which are more interactive and tailored to their audience can improve patient outcomes [10], and have recommended increasing the simulation-based content [11]. A Canadian national survey regarding the use of simulation in EM continuing professional development found that nearly all respondents desired increased simulation participation [12], and a similar single-site American study of academic EM faculty found 80% of faculty reporting procedural skill attrition with a desire for continued practice in the simulated setting [6].
With a clearly demonstrated need for simulation-based professional development programs, little information exists to guide prospective sites in the initiation of such a program. The objective of this survey-based study is to gather information on the state of existing simulation programs for attending EM physician learners in the United States, with a focus on exploring the modalities employed, content and incentives offered, and barriers encountered. We hypothesized that we would find a broad range of active simulation programs and anticipated primarily financial and time-based barriers to implementation and sustainability.
A workgroup comprised of members from the Society for Simulation in Healthcare (SSH) Emergency Medicine Interest Group (EMIG) and Society for Academic Emergency Medicine (SAEM) Simulation Academy collaborated to assess the overall current state of the EM simulation programs across the United States. We started the survey instrument design with a current literature review of simulation-based procedure education, including existing simulation programs targeting attending learners. We iteratively revised questions for scope and clarity through two rounds of refinement. Questions were open-ended with predetermined checkbox options when appropriate to determine the scope and content of simulation programs. We tested the survey through a limited pilot distribution within the SAEM Simulation Academy and SSH EMIG with minor changes added for clarity and readability. Using the SAEM Simulation Academy and SSH EMIG list serves, we distributed a 25-question, web-based survey issued through email invitation (SurveyMonkey) in May 2020, with a reminder email in November 2020. Respondents described their emergency department’s simulation programs for attending physicians, interest in such programs, and barriers to starting or expanding simulation for attendings. Data were evaluated with descriptive statistics.
Responses generated by the survey were a convenience sample of educators engaged in simulation-based organizations. A total of 28 educators responded to the emailed survey. Of the 28 program respondents, 16 (57%) identify as the emergency department simulation director, and six (21%) identify as a simulation center director. Fourteen respondents (50%) were from institutions in the northeast, seven (25%) from the midwest, three (11%) from each of the south and west, with one respondent unknown. Twenty-seven (96%) reported an academic affiliation, with four (15%) identifying community sites; three programs identified as both. Faculty reported salary support for teaching EM residents (88%) and medical students (57%) most often, with fewer faculty teaching EM attending physicians (34% academic, 23% community). Faculty also reported teaching various groups without salary support, such as medical students (25%), non-EM residents (28%), and attendings (23% academic and 7% community). Reported support of 0.1 to 0.3 full-time equivalents was true for 46% of respondents.
Eleven institutions (39%) reported a current attending physician simulation program, and four (14%) reported a prior program. Reported levels of participation varied, with only 29% of these programs reporting >75% of faculty attending SBE. See Table 1 for general descriptions of the responding programs. Of those programs that have since ended, limitations noted include scheduling challenges and limited staff engagement. The 17 respondents with no current attending program reported that their department would like to add SBE with high-fidelity cases (53%), interprofessional education (53%) or procedural skills instructions (47%). Notable barriers that programs reported to initiating or expanding simulation programs for attending physicians include lack of qualified facilitators to train attendings (76%), lack of dedicated time for both facilitators (88%) and participants (80%), and lack of funding (65%). Of respondents, 80% agreed that attending-focused simulation “must” include rare procedures on task trainers; 53% agreed that in situ simulation must be included, and 38% agreed that communication and interprofessional skills must be included.
Over the past decade, simulation has emerged as a recommended and preferred educational modality for competency-based assessments for learners across the continuum of experience. The finding that the majority of salary support reported here is for education of medical students and residents could be related to institutional, national, or certifying board requirements. However, this support has largely not been expanded to attending physicians in continuing education or MOC. Based on the responses here, there is significant interest in providing such programs for this population of learners, but barriers such as supported faculty and learner time are common.
The prevalence of interest in initiating attending physician SBE programs in both our data and the literature [6,12] highlights increasing acceptance of SBE as a learner-centered, experiential andragogy capable of promoting maintenance of competency and preventing knowledge erosion and skill decay. This aligns with previously published details on existing single-site programs [79] and the recommendation to improve availability of SBE for attendings [11]. Our findings do reveal, however, that the quantity and support for simulation programs for advanced learners lags in contrast to those for trainees in the specialty. Existing programs with high faculty participation in our cohort showed a trend of departmental buy-in in the form of mandated participation, a mix of high-fidelity, skills and quality-related activities, and lower faculty to learner ratios. The success of new attending-focused SBE programs may be ensured by providing dedicated time for attendings and facilitators, faculty development of simulation educators for attendings, and added funding for attending-focused programs.
One limitation of the survey data presented here is a predominance of academic programs, which may be related to the study population of primarily academic educators involved in the relevant groups. Due to composition of the distribution lists utilized, we are unable to determine a response rate since there is no available denominator. The survey is therefore a convenience sample. Additional programs beyond those presented here are likely to exist, but their educators were unable to respond to the survey. This nonresponse bias may have been impacted by lack of time or funding for ongoing simulation activities, or lack of interest in furthering SBE for attending physicians.
We present a summary of multiple geographically diverse simulation programs for attending physicians. The shared characteristics of these programs provide improved information for attending physician groups considering starting SBE for attendings. Existing programs are diverse but share some characteristics including departmental support of faculty and educator involvement, a range of simulated modalities, and consideration of quality-related initiatives. We identify the most common barriers as availability of instructors, availability of physician learners and instructors, and funding. Further work is needed to determine what simulation-based content is most high-yield to physicians in practice. Additionally, a formal scoping review could reveal gaps in the published literature on this topic. Through addressing the identified barriers in creative ways, educators can work to make simulation-based CME available for all attendings.

Ethics statement

This study was approved by the Institutional Review Board of Icahn School of Medicine at Mount Sinai (No. 19-1490). The requirement for informed consent was waived because the study was deemed exempt, and the data were de-identified.

NOTES

Author contributions
Conceptualization: all authors; Data curation: SMH, SKB; Formal analysis: SMH, AA, DS, SKB; Investigation: SMH, SKB; Methodology: SMH, SKB; Project administration: SMH, SKB; Validation: all authors; Visualization: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
The authors have no conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Data availability
Data analyzed in this study are available from the corresponding author upon reasonable request.

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Table 1.
Characteristics of existing simulation programs for attending physicians
Response no. No. of years Simulation/yr (hr) Faculty to learner ratio Participationa) (%) Purpose of participation Included procedure Facilitator Incentive Modality
1 9 6 1:2 >75 Skill practice, rare procedures, hospital credentialing, root cause analysis, education on teaching others, simulation to test clinical environment CVC, cricothyrotomy, chest tube, airway skills, debriefing skills, transvenous pacemaker, communication skills EMSim, EM faculty CME, mandated by chair, credentialing requirement High fidelity cases, interprofessional education, interdisciplinary simulation, procedural practice on a task trainer, standardized patient simulation, ultrasound, debriefing with attendings, education on teaching skills, education on debriefing skills, simulation to test/assess systems, in situ simulation
2 7 4 1:5 26–50 Skill practice, rare procedures, education on teaching others Cricothyrotomy, airway skills, debriefing skills EMSim, EM faculty, specialistb) CME High fidelity cases, procedural practice on a task trainer, standardized patient simulation, debriefing with attendings, education on teaching skills, education on debriefing skills
3 6 3 1:10 11–25 Skill practice, rare procedures, root cause analysis, simulation to test clinical environment Cricothyrotomy, chest tube, airway skills, debriefing skills, fiberoptic intubation EMSim, specialistb) - High fidelity cases, interprofessional education, procedural practice on a task trainer, ultrasound, debriefing with attendings, simulation to test/assess systems, in situ simulation
4 5 8 1:4 >75 Skill practice, rare procedures - EMSim, EM faculty Mandated by chair, monetary incentive High fidelity cases, procedural practice on a task trainer, debriefing with attendings
5 5 3 1:4 >75 Skill practice, rare procedures, hospital credentialing CVC, cricothyrotomy, chest tube, airway skills, conscious sedation EMSim CME, mandated by chair, credentialing requirement High fidelity cases, procedural practice on a task trainer, debriefing with attendings, in situ simulation
6 2 8 1:15 26–50 Skill practice, rare procedures, root cause analysis, simulation to test clinical environment Cricothyrotomy, chest tube, airway skills, debriefing skills EMSim, specialistb) Mandated by chair High-fidelity cases, interdisciplinary simulation, procedural practice on a task trainer, standardized patient simulation, ultrasound, debriefing with attendings, education on teaching skills, simulation to test/assess systems, in situ simulation
7 2 6 1:5 >75 Skill practice, rare procedures, simulation to test clinical environment CVC, cricothyrotomy, chest tube, airway skills, debriefing skills EMSim, EM faculty, specialistb) Mandated by chair High-fidelity cases, interprofessional education, interdisciplinary simulation, procedural practice on a task trainer, standardized patient simulation, ultrasound, debriefing with attendings, simulation to test/assess systems, in situ simulation
8 1 4 1:3 <10 Skill practice, rare procedures Cricothyrotomy EMSim, EM faculty - Procedural practice on a task trainer
9 1 1 1:1 11–25 Skill practice, rare procedures, hospital credentialing Airway skills, neonatal resuscitation EMSim Credentialing requirement High-fidelity cases, interprofessional education, interdisciplinary simulation, procedural practice on a task trainer, in situ simulation
10 1 2 1:1 51–75 Skill practice, rare procedures, education on teaching others CVC, chest tube, airway skills, debriefing skills, resuscitation EMSim, EM faculty Mandated by chair High-fidelity cases, interprofessional education, procedural practice on a task trainer, standardized patient simulation, debriefing with attendings, education on teaching skills, in situ simulation
11 1 4 1:5 51–75 Skill practice, rare procedures, root cause analysis Cricothyrotomy, airway skills EM faculty Mandated by chair High-fidelity cases, interprofessional education, procedural practice on a task trainer, debriefing with attendings, simulation to test/assess systems, in situ simulation
12 1 1 1:1 26–50 Simulation to test clinical environment Team leadership, communication skills EMSim - High-fidelity cases, interprofessional education, standardized patient simulation
13 1 2 1:4 26–50 Skill practice, rare procedures Airway skills, debriefing skills, ECMO EM faculty - Interprofessional education, procedural practice on a task trainer, ultrasound, debriefing with attendings, in situ simulation

CVC, central venous catheter; EMSim, emergency medicine faculty with simulation training; EM, emergency medicine; CME, continuing medical education; ECMO, extracorporeal membrane oxygenation.

a) Proportion of EM faculty participating in program.

b) Non-EM faculty from another specialty.

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