Adam I. Levine

Adding emotional stressors to training in simulated cardiopulmonary arrest enhances participant performance

Medical Education 2010: 44: 1006–1015

Role of Simulation in US Physician Licensure and Certification

The evolution of simulation from an educational tool to an emerging evaluative tool has been rapid. Physician certification has a long history and serves an important role in assuring that practicing physicians are competent and capable of providing a high level of safe care to patients. Traditional assessment methods have relied mostly on multiple-choice exams or continuing medical education exercises. These methods may not be adequate to assess all competencies necessary for excellence in medical practice. Simulation enables assessment of physician competencies in real time and represents the next step in physician certification in the modern age of healthcare.

The simulation theater: A theoretical discussion of concepts and constructs that enhance learning

The increasing role of simulation in medical education has paralleled the advancement of this technology. Full environment simulation (FES) can be used to effectively replicate rare medical catastrophes with exacting realism. It has been suggested that emotion can significantly enhance learning by producing memories that are processed and stored via the amygdaloid complex, which are relatively impervious to extinction and thus forgetting. Theoretically, the addition of emotional content to simulated crises during FES can be used to affect emotional changes in the participants and thus facilitate learning. Here, we discuss the theoretical benefit and the use of FES with emotional enhancement as it relates to improved memory and learning.

One approach to the return to residency for anesthesia residents recovering from opioid addiction

STUDY OBJECTIVE There is a high rate of relapse among anesthesia residents attempting to re-enter clinical anesthesia training programs after completing treatment for opioid addiction. Individuals may return to clinical practice after a short period of treatment only to relapse into active addiction, and for the opioid addicted anesthesia resident, this often results in death. The objective of this study was to determine weather or not a period of time away from clinical practice after treatment would reduce the rate of relapse by allowing the individual to concentrate on recovery in the critical first year after treatment, during which the majority of relapses occur. DESIGN 5 residents identified as being addicted to a controlled substance were removed from residency training and offered treatment. Prior to returning to residency training they were required to complete a post-treatment program involving no less than 12 months of work in the anesthesia simulator, followed by a graded re-introduction into the clinical practice of anesthesia. SETTING Academic anesthesia practice in a large teaching hospital. RESULTS Of the 5 residents who participated in the program, 3 (60%) successfully completed their residency program and their 5 year monitoring contract, and entered the anesthesia workforce as attending anesthesiologists. CONCLUSIONS The treatment of addicted physicians can be successful, and return of the highly motivated individual to the clinical practice of Anesthesiology is a realistic goal, but this reintroduction must be undertaken in a careful, stepwise fashion. A full understanding of the disease process, the potential for relapse, and the implications of too rapid a return to practice must be taken into careful consideration.

Simulation-based Maintenance of Certification in Anesthesiology (MOCA) course optimization: use of multi-modality educational activities

In 2010, the American Board of Anesthesiology instituted a new Maintenance of Certification in Anesthesiology (MOCA) Part IV activity requiring diplomates to attend and self-reflect on a simulation-based course in an American Society of Anesthesiologists-endorsed program. Although there are certain course requirements, much of the curriculum and structure of these MOCA activities is left to the discretion of the participating endorsed program. The ideal course would emphasize multimodality simulation-based activities that optimize diplomate education and satisfaction, while economizing faculty requirements. We describe of our course structure and content as a potentially useful template.

Bilateral sphenopalatine ganglion blockade improves postoperative analgesia after endoscopic sinus surgery.

Background Endoscopic sinus surgery (ESS) is a common procedure preferably done with an anesthetic technique ensuring effective postoperative analgesia while speeding discharge home. Although anesthesia administered locally in conjunction with vasoconstricting agents is known to minimize intraoperative bleeding, its usefulness in providing postoperative analgesia has not been well characterized. The results supporting the use of regional anesthesia for sinus surgery have also been limited. Using a randomized, double-blinded and placebo-controlled design, we evaluated recovery times, opioid consumption, and nausea and vomiting after ESS when patients were randomized to either general anesthesia (GA) alone or with regional blockade. Methods Subjects were 70 adults scheduled for sinus surgery. All participants underwent propofol/remifentanil/nitrous oxide anesthesia and similar intraoperative care. Patients received either GA alone or with sphenopalatine ganglion (SPG) blocks in a double-masked study design. Independent observers recorded readiness for discharge, incidence of nausea/vomiting, and pain scores every 15 minutes until discharge. Overall opioid use in the recovery area was also a secondary end point. Twenty-four hours later, patients were called and asked to rate their pain and overall satisfaction with their pain control. Results Block group participants were considered ready for discharge after 45 minutes and discharged from the hospital ∼40 minutes sooner than GA group participants. The block group required less total fentanyl in the recovery room than did the A group. The incidences of nausea and vomiting did not differ significantly. Data at 24 hours postoperatively did not differ significantly between groups but trended toward increased satisfaction in the block group. No lasting adverse events were observed. Conclusion Regional anesthesia using targeted nerve blocks is effective in ESS. The combination of GA and SPG blockade appears to shorten hospital stay and reduce narcotic requirements in the recovery area. No demonstrable benefits were observed after 24 hours regarding pain management.

The use of multimodality simulation in the evaluation of physicians with suspected lapsed competence

A simulator-based educational program has been incorporated into many anesthesia residency training programs. The effectiveness of this method of teaching has been validated by several studies and is generally accepted as an effective method of resident education. Evaluation of performance and positive critical feedback through debriefing has been attributed to the effectiveness of simulator-based education. Perhaps, this process can be used to evaluate the competence of practicing physicians. We report our experience using multimodality simulator technology to assess physicians who may have allowed their competence to lapse. We discuss our simulator-based assessment process and the strengths and limitations of our program. We also discuss the legal ramifications of participating in such assessments. Because of confidentiality agreements signed by all parties involved with this process, cases are discussed in general terms to assure anonymity.

Death in High-Fidelity Simulation: A Bioethical Analysis

With the growing popularity and increasing use of high fidelity simulation (HFS) in medical education, the appropriate role of simulated patient death in the curriculum has been debated from both an educational and ethical perspective. Given that HFS is a relatively new medical teaching modality, the prevailing uncertainty regarding the use of patient death to reinforce medical knowledge and decision-making likely stems from a lack of literature and open discussion on the topic. It is the goal of this paper to further explore the ethical implications of exposing learners in HFS to simulated patient death, with the hope of aiding in the development of effective curriculum for HFS programs.