10. Simulation in residency education

Introduction

Simulation is a powerful tool that consistently has large effects on learning and can even have meaningful impacts on patient outcomes.^1,2,3 The use of simulation in medical education has exploded in recent years and is on the radar of most program directors⁴ as an important teaching tool in their curriculum. While simulation-based education (SBE) is often talked about as a singular modality, the truth is that it is more like a toolbox.  Gaba described simulation as “… a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature…” to optimize the learning experience outside of the clinical world.⁵ These techniques may leverage different strategies or technologies such as task trainers, virtual reality, simulated patients, and theater-based simulation with mannequins to name a few. Key to learning from SBE is high quality feedback and/or debriefing in a safe learning environment, defined as an environment where it is safe to take interpersonal risks, and free from embarrassment, rejection, or punishment.^6,7 While simulation may have advantages over other techniques, as a Program Director planning curriculum, you often need to balance faculty energy, resources and time constraints and should seek high return on investment (ROI) for the typically high costs associated with immersive learning.^8,9 This chapter strives to support you in deciding where simulation can be helpful, how to integrate it into your curriculum, understand its use in assessment and how to optimize the ROI.  This chapter provides fundamental information and guidance around SBE, but for a deeper-dive into the topic, please consider one of the following texts:

Before thinking about integrating simulation into your program, it is important to understand what is available, such that you can maximize ROI based on your program’s needs and specific context.  Importantly, what is available in terms of simulation, will differ between programs and schools.  Also, many departments and institutions have a growing number of trained simulation-based educators who have focused expertise in this realm.  As a Program Director, you should consider working with these individuals, or even delegating the simulation components of your curriculum to a “Simulation Lead” or individual with this role in your program or department. If this is not available to you, it would be worthwhile connecting with other local simulation leaders or national communities of practice relating to simulation such as the Canadian Emergency Medicine Simulation Education Research Collaborative.¹⁰

Designing and Implementing Simulation-Based Education in your program: Using the ADDIE Model

There are many types of simulation modalities available to you when implementing SBE (Table 1). Further, there are a several factors to consider when choosing both the type of simulation and an effective strategy for integration into your training program. The ADDIE model is a useful instructional design framework to assist with your implementation. ^11,12 The cyclical design of ADDIE starts with an Analysis, followed by the Design, then Development, moving on to Implementation of the educational event and an Evaluation that can serve as an analysis to revise the curriculum (or sometimes develop another one).  The components of the ADDIE framework are used to frame the below sections describing key considerations for effective SBE implementation.  While you as a program director may not be directly developing the simulation, and understanding of a framework like ADDIE is helpful for you as you work with your simulation colleagues to design the overall curriculum.

Table 9.1 Types of simulation*

Simulation Type	Description	Use	Example
Synthetic Simulators and Task-trainers	Simulation using physical devices or structures that allow learners to acquire skills for a given task.	Typically used to develop technical skills prior to performance of procedures on real patients; may facilitate deliberate practice and mastery learning.	Lumbar puncture partial task trainers.16
Simulation on Human Cadavers and Animals	Simulation using live anesthetized or post-mortem animal tissues, and prepared human cadavers.	Traditionally used for procedural or technical training of advanced practitioners in situations where tissues characteristics and anatomical configurations mirroring human conditions are critical.	Airway management training on fresh frozen cadavers.17
Simulated and Standardized Patients	Simulation using a human patient as a surrogate; including role-play, real-patients, and simulated patients.	Real and simulated patients are utilized to allow trainees to experience real or mimicked clinical findings and situations in a standardized and controlled environment.	Simulated patient actors used to teach the delivery of bad news.18
Human Patient Simulators	Simulation using user controlled electronic manikins designed to reproduce the characteristics of a real patient.	Typically used in immersive critical care scenarios involving all aspects of clinical care.	Interprofessional cardiac arrest team training.19
In Situ Simulation	Using human patient simulation in a real clinical environment, at the point of care.	Typically used to either 1) engage multidisciplinary teams with maximized authenticity for training, or 2) test or improve clinical work environments (equipment, space, policies, procedures).	Design thinking-informed simulation as an innovative way to test and evaluate clinical infrastructure.20
Computer-based Simulation	Non-immersive computer generated simulation viewed and interacted through a computer screen and equipment.	Often used to simulate non-critical non-technical standardized clinical experiences for novice practitioners to learn in a safe environment.	Immersive virtual reality-based training for response to operating room fire situations. 21
Virtual and Augmented Reality	Immersive or semi-immersive multimedia simulated environments in which the user is an active participant via specialized headsets and/or controls.	Used to experience environments or clinical situations that cannot be easily physically recreated or explored, or to bring remote learners together.	Laparoscopic surgery VR simulators.22
Serious Games	Games (video, board, other) aimed toward problem-solving and learning rather than entertainment	Often used to teach non-technical competencies harnessing the educational value of play.	Gridlocked ED boardgame to teach about multiple patient environments. 23

*Adapted from Levine et al 2013, Pilote and Chiniara 2019 ^13-15

 

Analysis: Needs and Boundaries

Your analysis identifies the target learners, figuring out the critical elements to include in the learning activity and what the boundaries of the sessions / curriculum will be. Subject matter experts are needed to help define the important knowledge, skills and attitudes required. The needs assessment for the training can occur through local continuous quality improvement activities, patient safety events, direct observation of actual or simulated patient encounters, surveys (written or individual / group interviews) of residents or other stakeholders (faculty, other healthcare professionals or patients). When simulation is inter-professional, it is critical for you to actively engage educators in those disciplines to help guide the development of the sessions.

Simulation can be a powerful tool when it creates a safe learning environment,²⁴ and it can have important impacts when focused on difficult to teach topics, including everything from communication to resuscitation skills.  Implicit bias mitigation, anti-racism, effective advocacy and speaking up are critical areas for curriculum development and are highly sensitive areas where simulation may be impactful.^25,26,27  Understanding the needs of your stakeholders and where they align with curricular needs may empower you to effectively align goals to what is important and ask for more resources, if required.

Design: Educational Goals and Theory

Moving on to design, it can be helpful to write a goal-statement against which the training initiative will be measured. Ideally it would be specific, measurable, achievable, result-focused and time-bound. The next step should be defining learning objectives that can be cognitive, psychomotor or in the affective domains (recognizing that affective learning objectives are important to education despite being difficult or impossible to measure) and the appropriate simulation modality to achieve the goals (e.g. simulated patients for communication skills training).  It should be noted that isolated simulation-based activities tend to fail or be difficult to sustain momentum. Given the ‘cost’ of simulation (both financial and the opportunity cost of faculty diversion), integrating simulation into existing curricular elements or structure can be helpful to optimize use of limited resources and gain support of senior leadership / administration.  Wherever possible, SBE should reflect the range of difficulty and variety of clinical presentations trainees are exposed to in the clinical environment and, allow learners to train with the typical of tools and / or equipment that they are likely to encounter.⁶ Due to changes in clinical practice over the years, and advances in clinical care and technology, trainees in many specialties are doing substantially fewer procedures than they once did, so the role of simulation to develop and maintain competency across the range of presentations becomes amplified.

Instructors with subject matter expertise need to then develop or choose the simulation exercise, the debriefing guide and the appropriate assessment tools. The simulation modality chosen for a given purpose should be selected to best achieve functional task alignment; aligning the simulator’s functional properties with the functional requirements of the task.²⁸    In doing this, educators can optimize the transfer of learning.  Further, SBE should align with principles of deliberate practice and mastery learning.²⁹ In deliberate practice, the learner undergoes repetitive performance of skills / cognitive exercises that are supported by rigorous skills assessment. Learners receive actionable feedback which will help further skill development. Key concepts include setting appropriate objectives; at the appropriate level for the learner; allowing for performance that is observed with detailed feedback, that allows correction of errors; utilizing repetitive practice that allows increasingly competent skills performance. Mastery learning, a specific form of outcome-based education, is a rigorous approach to competency-based education. The aim is such that the time to learn a task will be variable (each learning will have their own learning curve), but that the learners will achieve mastery performance, with little or no variation. Mastery learning has been demonstrated to be effective in teaching across a broad range of resuscitation skills,^30,31 and using this approach has been shown to improve patient outcomes in central line insertion,³¹ thoracentesis,³²  paracentesis³³ and lumbar puncture¹⁴ and appears to be a cost-effective method of instruction.³⁴

Development and Implementation: Planning and Debriefing

Prior to implementation with the intended learner audience, a pilot or dry-run is particularly useful to identify issues with the scenario / educational activity that can be remedied before running with learners. This can be done with a different subgroup of learners (if feasible) or faculty and should focus on determining the quality of pre-brief, creation of a safe environment, the timing and quality of the scenario and the debriefing guides. For team training or Simulated Patient (SP) scenarios, you can anticipate some of the expected actions of learners which can be programmed into the manikin operating system software ahead of time or discuss with the SPs.

Simulation is a form of experiential-based learning, yet the most impactful moments of learning tend to be in the debriefing rather than the scenario itself.³⁵ Trained facilitators are critical to this process, and there is no singular ‘best’ technique – just some common principles. Debriefing needs to align with the case objectives but should allow the flexibility to incorporate learner driven learning goals that arise from within the simulation activity. Debriefers are advised to serve as the ‘guide on the side’ rather than the ‘sage on the stage’ and truly facilitate conversation to improve future performance. In order for that to happen, the debriefer needs to create a safe space (through activities such as a ‘learning contract’ and adequate time for pre-briefing the scenario and goals of the session). Specific techniques for debriefing such as plus-delta, advocacy-inquiry, directive feedback and rapid cycle deliberate practice are beyond the scope of this chapter but are important tools in the toolbox of debriefers.³⁶ Ultimately, the goal of debriefing can be considered in the larger picture of healthcare, where debriefing for clinical patient events can be utilized as part of continuous quality improvement in a learning organization and help improve patient outcomes. Program Directors more interested in debriefing might wish to read up more on the PEARLS model for a usable framework.³⁷

Evaluation: Return on Investment

Although the evaluation is placed at the end of the cycle, it really is an iterative process that should encourage reflective thought at each stage in the cycle.  When considering the overall evaluation of the simulation activities, you can use the familiar Kirkpatrick model^38,39 to facilitate subsequent adaptation. When implemented in this manner the evaluation can serve as a needs assessment for the next educational activities.

SBE is typically an expensive endeavor, so all efforts should be made to optimize the cost/benefit ratio.  One of the real challenges in navigating your resourcing conversations is that the cost of simulation is often easy to see, where the benefits while intuitive, may be more difficult to articulate.  Through the ROI lens, you can ask “what are we hoping to achieve and how will we know if we did” in conjunction with efforts to contain costs.  There are multiple costs to consider when planning simulation.  Fixed costs, such as operating costs of a simulation center and variable costs including teaching stipends/personnel, and equipment/technology need to be considered.  Understanding the “why” of your program allows you to focus your dollars to where it will be most impactful.  Often there are less expensive but equally educationally sound approaches to meet your curricular need.⁴⁰ Ask your simulation experts to help you minimize costs where you can.

It is important to understand who you are presenting your ROI to.  What do they care about?  There are several frameworks which organize outcomes of educational efforts.  In general, the models move from documenting improved knowledge/skills in a simulated setting to the more valuable, changes in practice and to patient or system outcomes.  For example, El Khamali et al (2018), demonstrated that an immersive simulation-based program for ICU nurses was associated with decreased job-related strain, absenteeism, and transfers Hospitals/ICUs may see that the costs associated with job related strain far outweigh the costs of a similar program.  While patient outcomes were not measured, this study may have dramatic impact on future funding decisions.

Simulation for Assessment

Current trends in postgraduate training, such as competency-based medical education (CBME), place an increased onus on training programs to ensure that graduating trainees meet key competencies before entering independent practice.⁴¹  Most programs look to the use of direct observation in the workplace to assure that these competencies are met, however the clinical workplace is not predictable and patient-care is prioritized over trainee assessment.⁴² To address these limitations, simulation-based assessment has been proposed as a potential supplement in programs of assessment,⁴³ with the capacity to control exposure to scheduled reproducible experiences and allow trainees to demonstrate their abilities without any risk to patient safety.⁴⁴ While in principle the simulated environment seems ideal for assessment, there are several tensions that have been noted.  For example, simulation was initially developed as a “safe space” for practice²⁴ and the introduction of assessment may threaten the integrity of this learning environment, with trainees fearing negative assessment.  Another concern is the variable access to simulation equipment and how this may disadvantage trainees and programs with resource limitations.

Despite these tensions, many of you have been tasked with the rapid integration of simulation into your programs of assessment without a clear understanding of how best to use it effectively.  In a review of the literature pertaining to simulation for assessment, Hall et al.⁴⁵ articulate a set of principles on the use of simulation for assessment.  Table 2 outlines the 6 key recommendations from this work.  We encourage you to reflect on these recommendations when considering the implementation of simulation-based assessment.  Here a few examples of how simulation-based assessment may be implemented:

• Rare clinical situations: If your trainees require assessment performing in a rare situation, you may want to consider arranging for this to occur in a controlled and predictable way using simulation, to supplement opportunistic exposure in the workplace.
• Communication and leadership: The simulation environment is particularly useful for allowing trainees to lead teams and communicate without intervention from attending physicians.
• Procedural competence before real-world performance: Demonstrating competence in a procedure or surgical skill prior to real-world performance minimizes potential harm to patients.

Table 9.2 Recommendations for the use of simulation-based assessment (SBA)*

Recommendations for the use of simulation-based assessment (SBA)
1. Validity evidence for assessment tools and processes in SBA should be aligned with the learner level and stakes of assessment.
2. SBA processes, such as rater training, case content, and assessment tools, should be standardized in order to support the reproducibility of assessment.
3. SBA is resource-intensive, so educators should utilize it only when other assessments will be less effective and match the level of fidelity to the objectives of assessment to minimize cost.
4. When performing simulation-based. assessment, educators should consider its educational effects and provide feedback to participants.
5. When designing SBAs, educators should engage in regular program evaluation and stakeholder consultation to ensure acceptability.
6. Educators should thoughtfully and purposefully incorporate SBA as part of a robust program of assessment.

*Adapted from (Hall et al. 2020) ⁴⁵

Simulation: A bright future in medical education

The potential uses of simulation in postgraduate medical education are increasing year over year, amplifying the impact of simulation on learners, teachers, and patients.  Certainly, traditional manikin and task-trainer-based simulation is now utilized in many postgraduate specialty training programs in Canada and abroad, but its implementation as a venue for assessment and certification is still in its nascence. With the introduction of in-situ simulation, there is increased opportunity for interprofessional and interdisciplinary learning,^46,47 and simulation for continued professional development.^48,49 Further, in-situ simulation affords the opportunity to use simulation as an investigative methodology to identify latent safety threats in clinical environments⁵⁰ and inform staffing workload and responsibilities in new settings and situations.⁵¹

In addition to increased uses of simulation, there have also been exciting technological advances that are offering new mechanisms for using simulation. The rapid improvement in 3D printing technology has made the creation and integration of partial task trainers much cheaper and easier, and has improved moulage and environment fidelity in some cases.⁵²   In addition, wearable technologies to measure trainee parameters, such as galvanic skin response and eye tracking devices are altering how we adjust simulation in real time and engage in effective debriefing.⁵³

Finally, the world of virtual and augmented reality is seen by many as the cutting edge of SBE.⁵⁴ Through the construction of artificial worlds or the projection of virtual information to enhance real environments, trainees will have the opportunity to interact with tissues, patients, and other healthcare providers, in unique and controllable ways.  From   laparoscopic surgery virtual reality simulators²⁰ to whole scale virtual hospitals and learning environments¹¹ virtual and augmented reality will undoubtedly shape the landscape of learning in the years to come.

Further reading

1. Levine AI, DeMaria Jr S, Schwartz AD, Sim AJ. 2013. The comprehensive textbook of healthcare simulation. Springer Science & Business Media.
2. Boet S, Granry JC, Savoldelli G. 2013. La simulation en santé De la théorie à la pratique. Paris: Springer.
3. Chiniara G. 2019. Clinical simulation: education, operations and engineering. Academic Press.
4. Nestel D, Kelly M, Jolly B, Watson, M. 2017. Healthcare simulation education: evidence, theory and practice. John Wiley & Sons.

References

1. Cook DA, Hatala R, Brydges R, et al. 2011. Technology-enhanced simulation for health professions education: A systematic review and meta-analysis. JAMA. 306(9):978-988.
2. McGaghie WC, Issenberg SB, Barsuk JH, Wayne DB. 2014. A critical review of simulation-based mastery learning with translational outcomes. Med Educ. 48(4):375-385.
3. Zendejas B, Brydges R, Wang AT, Cook DA. 2013. Patient outcomes in simulation-based medical education: A systematic review. J Gen Intern Med. 28(8):1078-1089.
4. Russell E, Hall AK, Hagel C, Petrosoniak A, Dagnone JD, Howes D. 2018. Simulation in canadian postgraduate emergency medicine training – a national survey. CJEM. 20(1):132-141.
5. Gaba DM. 2004. The future vision of simulation in health care. Qual Saf Health Care. 13 Suppl 1(suppl 1):i2-10.
6. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. 2005. Features and uses of high-fidelity medical simulations that lead to effective learning: A beme systematic review. Medical teacher. 27(1):10-28.
7. Kolbe M, Eppich W, Rudolph J, Meguerdichian M, Catena H, Cripps A, Grant V, Cheng A. 2020. Managing psychological safety in debriefings: A dynamic balancing act. BMJ Simulation and Technology Enhanced Learning. 6(3):164-171.
8. Lin Y, Cheng A, Hecker K, Grant V, Currie GR. 2018. Implementing economic evaluation in simulation-based medical education: Challenges and opportunities. Med Educ. 52(2):150-160.
9. Nestel D, Brazil V, Hay M. 2018. You can’t put a value on that… Or can you? Economic evaluation in simulation-based medical education. Med Educ. 52(2):139-141.
10. Chaplin T, Thoma B, Petrosoniak A, Caners K, McColl T, Forristal C, Dakin C, Deshaies JF, Raymond-Dufresne E, Fotheringham M et al. 2020. Simulation-based research in emergency medicine in canada: Priorities and perspectives. CJEM. 22(1):103-111.
11. Branch RM. 2009. Instructional design: The addie approach. Springer Science & Business Media.
12. Pirie J, Kappus L, Sudikoff SN, Bhanji F. 2016. Simulation curriculum development, competency-based education, and continuing professional development. In: Grant VJ, Cheng A, editors. Comprehensive healthcare simulation: Pediatrics. Cham: Springer International Publishing. p. 181-193.
13. Levine AI, DeMaria Jr S, Schwartz AD, Sim AJ. 2013. The comprehensive textbook of healthcare simulation. Springer Science & Business Media.
14. Pilote B, Chiniara G. 2019. The many faces of simulation. In: Chiniara G, editor. Clinical simulation. Academic Press. p. 17-32.
15. Chiniara G. 2019. Clinical simulation: education, operations and engineering. Academic Press.
16. Barsuk JH, Cohen ER, Caprio T, McGaghie WC, Simuni T, Wayne DB. 2012a. Simulation-based education with mastery learning improves residents’ lumbar puncture skills. Neurology. 79(2):132-137.
17. Kovacs G, Levitan R, Sandeski R. 2018. Clinical cadavers as a simulation resource for procedural learning. AEM Educ Train. 2(3):239-247.
18. Rosenbaum ME, Ferguson KJ, Lobas JG. 2004. Teaching medical students and residents skills for delivering bad news: A review of strategies. Acad Med. 79(2):107-117.
19. Dagnone JD, McGraw RC, Pulling CA, Patteson AK. 2008. Interprofessional resuscitation rounds: A teamwork approach to acls education. Med Teach. 30(2):e49-54.
20. Petrosoniak A, Hicks C, Barratt L, Gascon D, Kokoski C, Campbell D, White K, Bandiera G, Lum-Kwong MM, Nemoy L et al. 2020. Design thinking-informed simulation: An innovative framework to test, evaluate, and modify new clinical infrastructure. Simul Healthc. Publish Ahead of Print.
21. Sankaranarayanan G, Wooley L, Hogg D, Dorozhkin D, Olasky J, Chauhan S, Fleshman JW, De S, Scott D, Jones DB. 2018. Immersive virtual reality-based training improves response in a simulated operating room fire scenario. Surg Endosc. 32(8):3439-3449.
22. Beyer L, Troyer JD, Mancini J, Bladou F, Berdah SV, Karsenty G. 2011. Impact of laparoscopy simulator training on the technical skills of future surgeons in the operating room: A prospective study. Am J Surg. 202(3):265-272.
23. Tsoy D, Sneath P, Rempel J, Huang S, Bodnariuc N, Mercuri M, Pardhan A, Chan TM. 2019. Creating gridlocked: A serious game for teaching about multipatient environments. Acad Med. 94(1):66-70.
24. Rudolph JW, Raemer DB, Simon R. 2014. Establishing a safe container for learning in simulation: The role of the presimulation briefing. Simul Healthc. 9(6):339-349.
25. Chowdhury TI, Ferdous SMS, Quarles J. 2021. Vr disability simulation reduces implicit bias towards persons with disabilities. IEEE Trans Vis Comput Graph. 27(6):3079-3090.
26. Sukhera J, Watling CJ, Gonzalez CM. 2020. Implicit bias in health professions: From recognition to transformation. Acad Med. 95(5):717-723.
27. Vora S, Dahlen B, Adler M, Kessler DO, Jones VF, Kimble S, Calhoun A. 2021. Recommendations and guidelines for the use of simulation to address structural racism and implicit bias. Simul Healthc. 16(4):275-284.
28. Hamstra SJ, Brydges R, Hatala R, Zendejas B, Cook DA. 2014. Reconsidering fidelity in simulation-based training. Acad Med. 89(3):387-392.
29. Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. 2013. Simulation in healthcare education: A best evidence practical guide. Amee guide no. 82. Med Teach. 35(10):e1511-1530.
30. Donoghue A, Navarro K, Diederich E, Auerbach M, Cheng A. 2021. Deliberate practice and mastery learning in resuscitation education: A scoping review. Resusc Plus. 6:100137.
31. Barsuk JH, Cohen ER, Potts S, Demo H, Gupta S, Feinglass J, McGaghie WC, Wayne DB. 2014. Dissemination of a simulation-based mastery learning intervention reduces central line-associated bloodstream infections. BMJ Qual Saf. 23(9):749-756.
32. Barsuk JH, Cohen ER, Williams MV, Scher J, Jones SF, Feinglass J, McGaghie WC, O’Hara K, Wayne DB. 2018. Simulation-based mastery learning for thoracentesis skills improves patient outcomes: A randomized trial. Acad Med. 93(5):729-735.
33. Barsuk JH, Cohen ER, Vozenilek JA, O’Connor LM, McGaghie WC, Wayne DB. 2012b. Simulation-based education with mastery learning improves paracentesis skills. J Grad Med Educ. 4(1):23-27.
34. Cohen ER, Feinglass J, Barsuk JH, Barnard C, O’Donnell A, McGaghie WC, Wayne DB. 2010. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 5(2):98-102.
35. Fanning RM, Gaba DM. 2007. The role of debriefing in simulation-based learning. Simul Healthc. 2(2):115-125.
36. Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng A. 2016. More than one way to debrief: A critical review of healthcare simulation debriefing methods. Simul Healthc. 11(3):209-217.
37. Eppich W, Cheng A. 2015. Promoting excellence and reflective learning in simulation (pearls): Development and rationale for a blended approach to health care simulation debriefing. Simul Healthc. 10(2):106-115.
38. Kirkpatrick D. 1967. Evaluation of training. Training and development handbook. New York: McGraw Hill.
39. Moreau KA. 2017. Has the new kirkpatrick generation built a better hammer for our evaluation toolbox? Med Teach. 39(9):999-1001.
40. Raj D, Williamson RM, Young D, Russell D. 2013. A simple epidural simulator: A blinded study assessing the ‘feel’ of loss of resistance in four fruits. Eur J Anaesthesiol. 30(7):405-408.
41. Frank JR, Snell LS, Sherbino J. 2015. Canmeds 2015 physician competency framework. Ottawa: Royal College of Physicians and Surgeons of Canada.
42. Wang EE, Quinones J, Fitch MT, Dooley-Hash S, Griswold-Theodorson S, Medzon R, Korley F, Laack T, Robinett A, Clay L. 2008. Developing technical expertise in emergency medicine–the role of simulation in procedural skill acquisition. Acad Emerg Med. 15(11):1046-1057.
43. Griswold S, Fralliccardi A, Boulet J, Moadel T, Franzen D, Auerbach M, Hart D, Goswami V, Hui J, Gordon JA. 2018. Simulation-based education to ensure provider competency within the health care system. Acad Emerg Med. 25(2):168-176.
44. Ziv A, Wolpe PR, Small SD, Glick S. 2003. Simulation-based medical education: An ethical imperative. Acad Med. 78(8):783-788.
45. Hall AK, Chaplin T, McColl T, Petrosoniak A, Caners K, Rocca N, Gardner C, Bhanji F, Woods R. 2020. Harnessing the power of simulation for assessment: Consensus recommendations for the use of simulation-based assessment in emergency medicine. CJEM. 22(2):194-203.
46. Armenia S, Thangamathesvaran L, Caine AD, King N, Kunac A, Merchant AM. 2018. The role of high-fidelity team-based simulation in acute care settings: A systematic review. Surg J (N Y). 4(3):e136-e151.
47. Fung L, Boet S, Bould MD, Qosa H, Perrier L, Tricco A, Tavares W, Reeves S. 2015. Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: A systematic review. J Interprof Care. 29(5):433-444.
48. Forristal C, Russell E, McColl T, Petrosoniak A, Thoma B, Caners K, Mastoras G, Szulewski A, Chaplin T, Huffman J et al. 2020. Simulation in the continuing professional development of academic emergency physicians: A canadian national survey. Simul Healthc.
49. Petrosoniak A, Auerbach M, Wong AH, Hicks CM. 2017. In situ simulation in emergency medicine: Moving beyond the simulation lab. Emerg Med Australas. 29(1):83-88.
50. Fan M, Petrosoniak A, Pinkney S, Hicks C, White K, Almeida APSS, Campbell D, McGowan M, Gray A, Trbovich P. 2016. Study protocol for a framework analysis using video review to identify latent safety threats: Trauma resuscitation using in situ simulation team training (trust). BMJ open. 6(11):e013683.
51. Geis GL, Pio B, Pendergrass TL, Moyer MR, Patterson MD. 2011. Simulation to assess the safety of new healthcare teams and new facilities. Simul Healthc. 6(3):125-133.
52. Garcia J, Yang Z, Mongrain R, Leask RL, Lachapelle K. 2018. 3d printing materials and their use in medical education: A review of current technology and trends for the future. BMJ Simul Technol Enhanc Learn. 4(1):27-40.
53. Ross K, Sarkar P, Rodenburg D, Ruberto A, Hungler P, Szulewski A, Howes D, Etemad A. 2019. Toward dynamically adaptive simulation: Multimodal classification of user expertise using wearable devices. Sensors (Basel). 19(19):4270.
54. Kuehn BM. 2018. Virtual and augmented reality put a twist on medical education. JAMA. 319(8):756-758.