Creative Education
2014. Vol.5, No.1, 31-35
Published Online January 2014 in SciRes (
Simulation in Residency Training: A Review
Michael T. Flannery, Sharon Zahorsky
Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
Received December 3rd, 2013; revised January 3 rd, 2014; accepted January 10th, 2014
Copyright © 2014 Michael T. Flannery, Sharon Zahorsky. This is an open access article distributed under the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited. In accordance of the Creative Commons Attribution Li-
cense all Copyrigh ts © 2014 are reserv ed for SCIR P and the o wner of the in tellectual propert y Michael T. Flan-
nery, Sharon Zahorsky. All Copyright © 2014 are guarded by law and by SCIRP as a guardian.
Background: Simulation suddenly came into the limelight of regulation a few years ago when the Accre-
ditation Council on Graduate Medical Education (ACGME) recommended simulation training without
specifics. That left internal medicine program directors confused as they tried to figure out what was best
for their residents. Summary: The author’s review discusses the many issues and unanswered questions
regarding simulation training. It appears clear to this faculty member that residents enjoy the additional
training to make them more comfortable doing procedures related to their training. A few studies mention
longevity in retention of skills learned over time and very few discuss the numbers of procedures to attain
competency and outcome improvements if they occur. Conclusion: This leaves several areas that need
further study on the effects of simulation training in residency and meeting the needs of post-graduate de-
scriptions via surveys following training. What kind of procedures and clinical scenarios (codes, medical
dilemmas, ethical/communication issues), how often/how many, timing and appropriate measurements
especially if focusing on improved patient outcomes. This narrative summary utilized a review focusing
on simulation, internal medicine and various simulation outcomes.
Keywords: Simulation; Internal Medicine; Education
Simulation in Residency Training: A Review
Simulation has been defined as imitation or representation of
a process used in a controlled or monitored situation for the
purpose of training (Gabbai, 2001). Simulation has been uti-
lized for up to seventy years in the aerospace industry (Gabbai,
2001). The Accreditation Council on Graduate Medical Educa-
tion (ACGME) had a statement that appeared just a few years
ago that said “simulation should be utilized in the education of
residents”. Of course, this was a generalized statement without
specifics which sent program directors into a quandary. The
goals were thought to be to increase resident preparation for
various common medical procedures. There were several issues
to be determined including resident mastery and satisfaction,
length of retaining knowledge and skills and outcome im-
provement to decrease patient mistakes and injuries related to
the old see one, do one and teach one methodology. A literature
search was undertaken with the focus on various forms of si-
mulation training, competency and outcomes predominately in
internal medicine residency programs. The results of which are
described below.
Resident Simulation/Outcomes
The utilization of simulation has been studied in various
procedures including central venous catheter insertion (Barsuk
et al., 2009), lumbar puncture (White et al., 2012), cardiac ar-
rest (Healy et al., 2010) and emergency airway management
(Fraser et al., 2009). Other simulation studies reviewed long
term retention and transfer of abilities (Summerhill et al., 2007),
disaster preparedness (Barsuk et al., 2009), reduction of blood-
stream infections with invasive procedures (Bong et al., 2010),
physiologic stress during simulation and effects of feedback
and debriefing (Hayes et al., 2007). Defining which procedures
need to be mastered during residency usually can be found in
the program’s ACGME rules and regulations. However, this
typically generates a list of procedures with a possible numeric
attestation of how many need to be done to be competent.
Competency cannot be assumed and is not equally attained by
various residents. One might assume that patients would no
doubt be more comfortable knowing that there team of physi-
cians are well trained in the particular procedure they are about
to undergo.
One study demonstrated that residents feel unprepared and
unsupervised as leaders of cardiac arrest teams. Only 52% felt
prepared to lead a cardiac arrest team with 55% worrying that
they made errors (Brim et al., 2010). Another study, regarding
studenttraining on simulation during a medical clerkship, dem-
onstrated that during a 6 year period 327 Harvard students par-
ticipated in a simulator based teaching experience on the prin-
ciples on myocardial infarction (MI), in addition to their 12
week medicine clerkship curriculum. Ninety-nine percent of
students found the experience valuable with >69% requesting
multiple sessions. When compared with real life experiences,
78% had a didactic session on MI and 47% had an exposure to
a patient with an MI (Sharpe et al., 2010). Another considera-
tion is stress levels during simulation versus traditional teach-
ing. One study reviewed 27 gastroenterology physicians who
were randomized to simulation based training (SBT) versus
traditional based training (TBT) involving tutorial based inter-
active training. Physicians exposed to SBT experienced greater
increased in heart rate and salivary cortisol when compared
with TBT (Hayes et al., 2007). The effects of such physiologic
stimulation to SBT on cognition and retention need to be stu-
died further.
One of the major changes in the ACGME rules and regula-
tions in the past 10 years have been resident work hours. The
effect of excessive work hours and fatigue has also been studied
when reviewed in relevance to simulation training. Residents
undergoing a 26 hour work shift were studied at four different
points on 8 different simulated rhythm disturbances. While
improvements were made between points one and two there
was significant increase in errors from 0.92 to 1.58 from the
first to fourth sessions (Gordon et al., 2010). Another study
reviewed simulator scores after an extended shift of 24-30
hours compared to a rested state. Again scores were signifi-
cantly lower and consistent with prior real time hospital studies
using the same shift schedule (Barsuk, 2011).
Another collateral effect, that was unexpected but benefi-
cial ,was the effect of SBT for central venous insertion in senior
residents on the improvement of junior residents’ skills/scores
(Barsuk et al., 2009). The mastery of the procedure was main-
tained for a least one year as noted in many other studies. One
could easily surmise that senior residents would take time to
educate their junior residents on proper technique which would
improve scores. However, this in no way should replace SBT
for junior members as there is great variation amongst residents
even when utilizing the old way of see one, do one and teach
one which is not appropriate to high risk, low frequency events
such as cardiac or respiratory arrest.
One of the most commonly studied internal medicine proce-
dures in the SBT setting is central venous catheter (CVC) inser-
tion. This common to many of the core residencies and, there-
fore, is not a surprise that it was studied extensively. In one
study set in the MICU, no residents met a passing score at
baseline for CVC insertion. Residents undergoing simulated
CVC insertion demonstrated more self-confidence and fewer
passes for CVC insertion (Smith et al., 2010).A similar study,
CVC procedural skills improved but decayed to the control
group after a period of time. The was thought secondary to the
low number of CVC insertions during that rotation averaging
1.7CVC’s over a 3 - 4 week period of time (Evans et al., 2010).
Another study randomized, controlled, single blinded study of
first and second year residents reviewed 495 CVC insertions by
115 residents over 21 months. SBT was associated with signi-
ficance at first time successful insertion of the CVC (Barsuk et
al., 2010). Finally, another CVC insertion studied focused on
long term retention of skills. Whereas 100% of residents passed
simulation training initially, there was some decay with 82-87%
passing simulation or post testing scores at one year. The au-
thors suggested that the residents should have periodic testing
and perhaps a refresher course (Cohen et al., 2010). If simula-
tion can improve CVC procedural skills, how about the out-
comes, such as infection rates? This was reviewed in 2010
looking at catheter related bloodstream infections (CRBI) after
simulation training in the MICU. Approximately 9.95 CRBI’s
were prevented among MICU patients in the year after the si-
mulation intervention. The cost of the education intervention
was 112 thousand dollars and compared with the cost of treat-
ing the CRBI for 2 weeks resulted in a net annual savings
greater than 700 thousand dollars. Compared to other ICU loca-
tions, in that hospital system, in which no intervention occurred,
there was no change in CRBI’s (Mayo et al.,2004).
Simulation of airway emergencies is particularly important in
reviewing training responses to high risk but low frequency
events such codes requiring airway placement. One study ran-
domized interns after advanced cardiac life support training to
immediate simulation or delayed simulation. Those receiving
immediate intervention showed significant improvement im-
mediately after intervention and at 4 weeks. The improvement
appeared to be transferable to the patient’s bedside via attend-
ing evaluation. The delayed group showed no improvement
(Mayo, 2004). The latter group received their testing at a later
time to attempt to exclude the possibility that the testing itself
was not a demotivating factor. The initial group of interns re-
ceived a simulation intervention which was repeated at 6 weeks
and then they were monitored throughout the following year by
attending’s. All starting interns had poor scores that improved
significantly after the intervention and was maintained on re-
testing and during patient events throughout the year (Rosenthal
et al., 2006). Another study, reviewed airway management
skills of senior residents. They were randomized to the SBT (si-
mulation based treatment) versus TBT (traditional based treat-
ment). TBT was random experiences of residents during code
situations. The SBT group performed better than the TBT group
in 8 of the 11 steps of a respiratory arrest protocol. Therefore,
traditional training over 2 years was insufficient to achieve
proficiency without SBT. This is particular concerning as they
may have had several unit experiences and been the team leader
on codes for up to one year previously (Kory et al., 2007).
As mentioned previously, when it comes to cardiac arrest and
codes residents feel unprepared but also 73% of residents re-
ported that they did not receive staff supervision during week-
days and that number increases to 96% for weekends (Brim et
al., 2002). In one of the first ACLS (Advanced Cardiac Life
Support) longitudinal studies, small group simulation on tradi-
tional ACLS via eight hours on the simulator assessing six si-
mulated scenario’s. The residents were followed up for 14
months and showed no significant decay in their ACLS skills.
(Wayne et al., 2008) Of course, one limitation is the low fre-
quency of events over such a time period which depends on
unit assignment and night call for the code team backup. One
study reviewed the comfort level of senior internal medicine
residents with in-hospital resuscitation. There were five differ-
ent knowledge sets reviewed including cardiac rhythm assess-
ment, delivery bad news, and discussion of code status, wide-
complex tachycardia and bradycardia management. In addition,
skills sets were included defibrillation, airway management,
central venous access etc. Only 28% of residents felt prepared
before the course and after the course 45% of participants re-
ported using the knowledge and skills taught with a significant
mean improvement in confidence (Healy et al., 2010). Another
simulation based education on adherence to American Heart
Association standards showed significant adherence with an
odds ratio of 7.1 on SBT versus TBT in third year residents.
SBT residents were not followed longitudinally (Wayne et al.,
2008). In a cardiac arrest debriefing of the weeks prior cardi-
opulmonary resuscitation (CPR) events led to significant CPR
improvements but no change in survival at discharge (Edelson
et al., 2008). Simulator based cardiac exam competence com-
bined with checklists also improved cardiac exam performance
by residents in internal medicine (Hatala et al., 2009). A simu-
lation evaluation of cardiac fellow performance on interven-
tional cardiac procedures was able to identify weak performers
beyond that of written examination. This allowed immediate
feedback in potentially difficult situations and could be inte-
grated into the written curriculum (Lipner et al., 2010).
Internal medicine residency programs at centers with emer-
gency medicine residencies often lack enough lumbar puncture
(LP) experience. This is due to the fact that many of the emer-
gency room residents perform the procedure before the medi-
cine residents arrive to evaluate the patient. Therefore, this is
another area to focus on for simulation and subsequent patient
skills. One study evaluated simulated trained internal medicine
interns against traditionally trained neurologists. The interns
nearly doubled their scores and outperformed the trained neu-
rologists (Barsuk et al., 2012). One more recent study found
that only 29% of interns performed an LP (lumbar puncture) in
medical school and only 9% have done more than 5 LP’s
(Gaies, 2007). Another study, looking at pediatric interns,
found a 12% improvement on pre-test versus post-test scores.
Utilizing a checklist after the intervention interns averaged 9.7
of the 11 checklist points with the number of averaged attempts
at 1.4. Forty-eight percent of the interns performed the proce-
dure correctly. Survey data demonstrated that confidence im-
proved with the number of procedures undertaken (White,
Another area fearsome to residents is the intensive care ex-
periences where a wide variety of procedures may need to be
undertaken during the rotation. Studies on simulation based
education in the medical intensive care units demonstrated that
SBT interns scored higher on bedside skills assessment when
compared with TBT interns and such skills were transferable to
actual patient care (Schr oedl et al., 2012). SBT resident’s also
demonstrated higher levels of satisfaction with their SBT. Other
studies showed that debriefing sessions utilizing a checklist
allowed evaluation of resident performance in critical care
standards (Clay et al., 2007; Lighthall et al., 2003). Similar to
other studies residents improved their short term skills, im-
proved confidence, decreased errors and had higher levels of
satisfaction. The areas that need further study include longer
term effects and outcome measures that demonstrate improved
morbidity and mortality evidence.
Number of Procedu res Needed for Competency
Another area to evaluate is how many procedures a resident
needs to do in order to achieve competence. Traditionally, uti-
lizing the ABIM procedure books it was stated that 3 - 5 pro-
cedures need to be completed to achieve competency for the
most common procedures. Most program directors would no
doubt agree that such numbers are inadequate across the board.
A number of studies have indicated that to achieve a comforta-
ble or very comfortable level of confidence roughly 65% of
residents achieve this level having done 6 - 10 procedures. Su-
pervision and repetition were critical components of comfort.
Procedures requiring higher numbers to achieve such comfort
were central venous access and endotracheal intubation (Huang
et al., 2006; Smith et al., 2004). Comfort levels were consistent
with experience with post-graduate year (PGY) one at 34%
comfortable handling procedures to 71% for PGY 2 and 61%
for PGY 3. The decrease in the PGY3 year certainly may be
due to the predominance of elective rotations out of the lime-
light of the intensive care units. To improve comfort and,
hopefully, competency levels one program initiated an inpatient
proceduralmedical service with a designed curriculum and me-
chanisms of evaluation (Smith et al., 2004). One paper de-
scribed four stages of competency development for procedures
from knowledge to exposure to skill acquisition and finally,
competence usually determined via checklists or simulation
training (Manthey et al., 2012).
Current policies and procedure requirements for the Ameri-
can Board of Internal Medicine (ABIM) indicate a minimum of
5 procedures the resident should perform safely and compe-
tently which included; advanced cardiac life support, drawing
of venous and arterial blood, Pap smear and endocervical cul-
tures and placing a peripheral venous line. It is certainly rea-
sonable to believe that the drawing of venous and arterial blood
and the placement of a venous access is something that can be
competently achieved in medical school. For other common
procedures a n internist should be able to know, understand and
explain the indications, complication, sterile technique, pain
management, sterile handling, interpretation of results, know-
ledge to obtain informed consent (ABIM, 2013). There is no
mention of how many procedures need to done to achieve
competency. Many recognize 3 components to achieving com-
petency which include; knowledge, differentiation between
normal and abnormal findings and testing such as simulation
(Norris et al., 2007).
Determine the number of simulation procedures will vary to
some degree depending on what specialty a resident may enter.
OF course all internal medicine residents should experiences a
core of procedures as specified by the ABIM and ACGME.
Respondents to a 2004 survey indicated EKG (Electrocardio-
gram) interpretation (200) as number one procedure completed
followed by microscopic examination of the urine (100). Other
high areas (> 50 median number of procedures in the past year)
included CXR (Chest X-ray) examination (90), cryosurgical
removal of skin lesions (50), esophagogastroduodenoscopy (50),
colonoscopy (87) and treadmill exercise testing (50). Most
other procedures were 10 or less over the past year including
CVC placement (10), thoracentesis (3), paracentesis (2) (Wig-
ton et al., 2007). The survey though 9 years old indicates that
surveying post-graduates from your program is an important
process to identify any procedural needs that went untaught or
trained during their residency.
In summary, every program with the support of their gradu-
ate medical office must determine which and how many proce-
dures should be performed at specific times to achieve compe-
tency per the individual resident. Clearly simulation improves
immediate confidence and performance across a wide variety of
procedures in different situations. Assigning a base number of
procedures that need to be completed as the residents finish
their PGY1 year and PGY3 year for internal medicine may be
necessary. However, they are very likely to be higher than the
ABIM has li sted as expectations of 3 - 5 procedures. Given the
fact that much of the evidence demonstrates decay in simula-
tion skills repetition at various points during residency will be
needed across a broad number of clinical scenarios. These may
include codes, medical emergencies and ethicaldilemmas. This
is also an opportunity to invest in joint ventures with the hos-
pital so that necessary personnel such as Anesthesia, nursing
and pharmacy participate in the simulation and debriefing
Another area for investigation is monitoring outcome mea-
surements which should be undertaken as a part of the quality
review process. This would be applicable not only to the quality
of the simulation training but the study of the evidence that may
support improved patient outcomes. It would seem reasonable
to this author that some basic ACLS and medical emergencies
are on a continuum from the student’s clinical UME to their
GME experiences. These basic skills can then be further rein-
forced during their residency training. Certain procedures, such
as central venous line placement, thoracentesis, paracentesis,
arthrocentesis and lumbar puncture can be practiced in the si-
mulation lab at the beginning of their PGY1 year and then re-
peated at the end of the year before approval to do such proce-
dures independently as a PGY2 supervisor. This would be ac-
complished via faculty participation at key points and during
the debriefing process. In between, ongoing checklists can be
utilized on real patient procedures to insure procedures that are
done correctly and minimize error and stress. Future studies are
necessary to determine how many procedures need to be ac-
complished for each given resident with minimal numbers set
between 6 - 10 based on prior studies before advancing to the
PGY2 year and perhaps higher prior to graduation. Obviously,
some residents may need additional training in specific clinical
dilemmas or procedures so one number does not equal compe-
tency for all.
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