Still image from a video of the simulation training for PGY-1 residents in the “OrthComSimLab” at the University of Mississippi Medical Center.
Courtesy of John M. Purvis, MD


Published 9/1/2014
Donna Phillips, MD; John M. Purvis, MD

Simulation Training and Assessment: It’s Not Just For Technical Skills

Orthopaedic residency programs are required by the Accreditation Council for Graduate Medical Education (ACGME) to teach and assess residents in the following six core competencies:

  • patient care and procedural skills
  • medical knowledge
  • practice-based learning and improvement
  • interpersonal and communication skills
  • professionalism
  • systems-based practice

Under the newly introduced Next Accreditation System used by the Accreditation Council on Graduate Medical Education to assess program outcomes, milestones are used to verify that residents are moving through appropriate educational developmental landmarks. Many residency programs have recognized that prior methods can be inadequate to truly measure resident competency for the milestones. As a result, they have turned to simulation both to both teach skills and to assess resident competence. As a training tool, simulation can drive down costs, improve efficiency, and lower complication rates.

Surgical skills simulation is an accepted method to assess resident competence. Basic simulation stations can determine the residents’ ability to place guide-wires consistently and use saws to make accurate and safe cuts. High-fidelity equipment can verify arthroscopy skills before the resident actually performs the procedure on a real patient.

Assessing residents in the nontechnical core competencies with the same objectivity and consistency as in the technical competencies, however, has been more challenging. Interpersonal and communications skills, systems-based practice, and professionalism are not only difficult to teach, but also to measure. In our two residency programs, we have found simulation to be a useful teaching and measurement tool for nontechnical competencies.

Simulated conversations
At the NYU Hospital for Joint Diseases (HJD), all residents participate in an Objective Structured Clinical Examination (OSCE) with stations that assess the resident’s ability to manage difficult conversations with standardized patients and standardized healthcare professionals. Such simulation stations include the following:

  • recognizing and delivering bad news
  • getting informed consent from a patient
  • having a postoperative conversation with a father after an intraoperative error
  • negotiating with a nurse on the phone to provide timely care for a preoperative patient

This OSCE provides the opportunity for residents not only to practice realistic conversations, but also to get feedback on their communication skills and professionalism through a checklist and review of video recordings of the simulations. As one resident admitted, “You can’t deny your mistakes when they are on the video.” These simulated conversations have had a lasting impact on resident interactions with patients and other healthcare professionals.

The next step is to assess how residents perform when they are unaware of being observed. At NYU HJD, this is measured in a program of unannounced standardized patients (USPs) who come to the clinic as “real” patients. The USPs are aware of the communication skills expected to be used by the resident and the physical exam that should be performed.

This program not only provided information about the residents as a group, it also enabled us to measure the clinic environment and patient-safety issues such as using two identifiers and hand-washing. Through these simulations, we learned that residents make the correct diagnosis in only about half the visits and the history and physical exam were often incomplete.

As a result of the USP program, NYU HJD modified the curriculum in the early residency years to emphasize history taking and the physical exam. Interns participate in intensive, interactive physical exam skills. At the end of a month devoted to skills training, they participate in an OSCE with milestone-specific cases that include taking a history, performing a physical exam, establishing a diagnosis, and developing a plan with the patient about further imaging and potential treatment options. The interns view their videos for completeness of the physical exam using a checklist, the standardized patients evaluate the interns’ communications skills, and the interns receive feedback comparing their OSCE performance to their peers.

At the University of Mississippi Medical Center, first-year residents participate in simulation scenarios developed for preoperative, surgical, and postoperative settings. A realistic environment for each scene is established in the OrthComSim Lab. The patient is a high-fidelity mannequin, and experienced nurses, scrub techs, anesthesiologists, and other staff volunteer as role players. The goal is to teach and evaluate aspects of communication skills, professionalism, and the use of systems-based practices, rather than the technical aspects of a surgical procedure.

Realistic interactions with the role players as well as actual equipment and room settings are important for each scenario. Many potential failure points can be sprinkled throughout each scenario. These include the following:

  • not communicating with the patient’s spouse
  • not introducing self and team members
  • improper use of checklists and time-outs
  • wrong site marking
  • ignoring the anesthesia team

Two residents participate in the opening scenarios while two other residents view the action from a separate room. A brief review and didactic session is held before the residents switch roles for the closing scenarios. After the sessions, everyone—residents, role players, and teachers—view video recordings and participate in open discussions to evaluate the residents’ performance and offer constructive suggestions. These observations contribute to baseline milestone measurements for each resident.

Additional opportunities
Beyond the examples from these two programs, simulation can be used to meet other needs in a residency program. For example, residents may not have an opportunity to manage an emergency in the operating room during residency training. A simulated scenario can be used to assess the residents’ ability to incorporate what they have learned about working with a team during an emergency, determine if the curriculum has been adequate to prepare them, provide an opportunity to practice a rare event in a safe environment, and get immediate feedback.

OSCE can be used to assess practice-based learning, one of the core competencies not assessed consistently in residency. Such an OSCE station includes a situation in which the resident has to make a decision about the need for immediate or emergency care. The simulation includes options for treatment, and the resident must research the literature as well as make a decision within a prescribed period of time.

In summary, innovative educational modules can be developed to address the needs of residency programs to teach and assess all the core competencies. Additionally, based on the data generated, resident education can be individualized. Simulation modules for orthopaedic training and assessment can be used effectively for much more than just technical competencies.

Donna Phillips, MD, is chief of pediatric orthopaedic surgery at the Bellevue Hospital Center, director of orthopaedic resident assessment and assistant residency program director at the NYU HJD department of orthopaedic surgery; John M. Purvis, MD, is a member of the AAOS Now Editorial Board and an associate professor in orthopaedics at the University of Mississippi Medical Center.

Bottom Line

  • Simulation techniques can be applied to both technical (surgical) and nontechnical (communication, interpersonal skills) competencies.
  • Role playing, standardized patient scenarios, and emergency drill practices are examples of education modules involving simulations that can be used to test resident proficiency in core competencies.
  • Simulated patient encounters with trained individuals can provide information about the resident’s skills to enable an individualized educational approach.

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