Introduction

Medical simulation is an effective method to teach high-risk procedural skills, identify latent safety threats in healthcare, improve patient safety, and develop teamwork and communication skills.[1][2][3][4] As the field of medical simulation continues to grow rapidly, fellowship training in medical simulation also continues expanding to meet the growing demand.[5] In only ten years, over 45 new simulation fellowships have started worldwide.[5] With increased utilization of medical simulation in training, there is an associated increase in demand for well-trained, effective simulation educators.[6][7][8] Simulation fellowships exist to provide this training and generate graduates who are successful in administrative skills required to operate a simulation center, effectively facilitate and debrief learners, design curricula to achieve educational objectives, and publish simulation-based research to further the specialty.[5][9]

The rapid expansion of simulation fellowships has led to a lack of standardization in the fellowship curriculum.[5] While this allows for tailored training toward trainee interest, it also creates wide variability in the curriculum and potentially limits the transferability of fellowship training.[4]  Medical simulation fellowships have not obtained accreditation from the Accreditation Council on Graduate Medical Education (ACGME) or Royal College of Physicians and Surgeons of Canada (RCPSC).[4][9] Surgical simulation fellowships do have accreditation from the American College of Surgery.[10] The content and structure of medical simulation fellowships vary, as evidenced by previous studies surveying fellowship program directors and graduates.[4][5][9][11]

Function

Medical simulation fellowships serve to train graduates to be effective experts in simulation.[9] Graduates can facilitate high-quality simulation sessions and effectively debrief learners utilizing a variety of methods. Medical simulation fellowships often include principles of adult learning and simulation design to teach curricular objectives.[9] Educators often use high-fidelity manikins for medical simulations; fellowship graduates often receive training in operations as well as procedural task trainer use and maintenance.[4][11] Medical simulation fellowships can include additional time for a master’s degree in health profession education or an educational certificate.[4]

Issues of Concern

Medical simulation fellowships, likely due to their unaccredited nature and rapid expansion as a specialty, lack standardization of core curricular content.[4][5][11] There is much debate about standardizing the core objectives of medical simulation fellowships to allow for more transparency and whether board certification or accreditation should be a requirement.[4][5] The majority of program directors agree that standardization of either fellowship guidelines or core objectives is necessary.[11] Few program directors rated board certification as necessary on a survey of international medical simulation fellowship program directors.[11] The majority of medical simulation fellowship program directors felt that board certification would be detrimental to the specialty, citing potential future limitations on growth and innovation.[11]

Medical simulation fellowship graduates, when surveyed, also report varied experiences.[9] Areas for improvement in most medical simulation fellowship programs, as identified by graduates, include research, simulation technology, and administration.[9] These opinions align with a previous study of fellowship program directors, finding that the majority of medical simulation fellowships do not include simulation-based research as a critical fellowship activity.[11] However, most fellowships require an abstract and national presentation for graduation.[5][11] Only half of the fellowship graduates reported a manuscript submission.[9] Simulation-based research leads to advancement and innovation in the field. It is an essential aspect of medical simulation fellowship training to produce fellowship graduates who are adequately prepared for a career in medical simulation and often academic medicine.[9][11]

Curriculum Development

Medical simulation fellowship trainees have common characteristics.  The majority of fellows are physicians who have completed residency training, most commonly in emergency medicine, anesthesiology, or general surgery.[5][11][12] Nurses, nonclinical educators, and paramedics have also completed medical simulation fellowships.[11] Most fellowships are one to two years in length, supported by medical schools or hospitals, and graduate one to two fellows annually.[11][12] Clinical service or departmental funds most often support funding for fellowships.[5][11] Most fellows do not pay tuition fees.[11] During the fellowship, fellows reported averaging approximately 10 to 20 hours per week on simulation activities and from 11 to 20 hours weekly on clinical duties.[5][9][11] Fellows are likely to receive educational funds to support their attendance at national conferences as well as further development at workshops or courses.[11]

Surveys of medical simulation fellowship program directors have illuminated core curricular objectives and common themes for fellow education. The majority of program directors agreed that fellowship objectives should include medical simulation curriculum development, research and scholarly activity, simulation operations including organization, execution, assessment of simulation activities, principles of debriefing, simulation methodology, educational theory, and administration, including leadership and advocacy.[5][11][12] Assessment and formative evaluation of both fellows and fellowship programs occur in most medical simulation fellowship programs.[5] Few fellowship programs perform a summative evaluation of fellows.[5]

A consensus project by Frallicciardi et al. utilized emergency medicine simulation experts and sought to define core content for emergency medicine simulation fellowships, which may apply to non-emergency medicine fellowships as well.[4] These essential curricular objectives serve to build a common foundation for emergency medicine simulation fellowship training.  As outlined in this project, key domains were agreed upon to be crucial to fellow education and were further defined into curricular content; this included the development of simulation-based curriculum domain, with comprehension and utilization of a variety of conceptual frameworks in simulation design, as well as evaluation of simulation-based training education efficacy and participant performance. In the technical operations domain, the researchers agreed that fellows should have expertise in the operation of various trainers and manikins, incorporate technology into simulations as appropriate based on objectives, and specifically utilize simulation in crisis resource management training and patient safety efforts. The project further defined administrative domain content as management skills, financial understanding of simulation center operations, simulation staff employment, and advocacy for simulation activities within an institution/department. The simulation research domain recommended fellows develop an understanding of simulation-based research methodology and complete a scholarly project. In the domain of teaching and education, curricular content included expertise in debriefing, using the simulation for interprofessional and interprofessional activities, training learners of all abilities, and giving both summative and formative feedback to learners. The simulation theory domain included an understanding of key issues, theoretical foundations, and conceptual framework that define simulation-based education and its best practices. This domain also includes knowledge of supporting simulation-based educational literature.[4]

Continuing Education

Continuing education of simulation-fellowship trained faculty remains a critical aspect in the specialty of medical simulation. There are several opportunities for faculty development in medical simulation, including educational courses, workshops, and national and international conferences.[4] Topics for medical simulation faculty development include research, grant writing, debriefing, standardized patients, and mastery learning, among many others.

Clinical Significance

Medical simulation and simulation-based education continue to be at the forefront of medical training and patient safety efforts.[1][2][3][4]  Medical simulation fellowships provide highly trained and well-qualified graduates who can navigate the field of medical simulation successfully, provide theory and framework-based curriculum, skillfully debrief participants to stimulate critical thinking, and publish evidence-based simulation research.[5][9][12] Graduates of medical simulation fellowship receive specific training to use the simulation for team-based training, interprofessional education, crisis resource management skill training, and communication.[5][9][11][12] The desire for high-quality simulations continues to increase the need for medical simulation fellowship-trained educators, likely due to the specific skills and knowledge learned during the fellowship.[5][6][7][8]

Enhancing Healthcare Team Outcomes

Patient safety in healthcare is an area of increasing attention worldwide.[1][2] [Level 2] Medical simulation is an educational method by which teamwork, communication, and crisis resource management instruction can be more effective.[5][11][13][14] [Level 3]  Preventable patient harm is reduceable through nontechnical skills training and crisis resource management training.[13][14] [Level 3] Procedural training and simulation-based mastery learning curricula have also been shown to decrease rates of infection and procedure-related complications in actual patient care.[15][16] [Level 3]