Simulation in emergency medicine graduate medical education: a call to lead

Article information

Clin Exp Emerg Med. 2023;10(1):107-109
Publication date (electronic) : 2023 January 30
doi :
Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
Correspondence to: Andrew D. Bloom Department of Emergency Medicine, University of Alabama at Birmingham, 1720 University Blvd, Birmingham, AL 35294, USA Email:
Received 2022 December 15; Revised 2023 January 13; Accepted 2023 January 16.


Simulation-based medical education made its first considerable appearance in graduate medical education (GME) in the late 1980s, as Gaba and DeAnda began to pioneer the use of immersive simulation for anesthesia residents in operating rooms at Stanford University in California, USA [1]. Since that time, the needs of learners have continued to evolve as the apprenticeship model for medical education has shifted in favor of clinical skills training [2]. Simultaneously, the expectations of our patients have also changed. Whether it was ever acceptable to “practice” a trainees first critical procedure on a patient is its own topic of debate, but expectations have changed regarding patient safety and the basic procedural skill levels required prior to performing these procedures [3]. In many ways, the classic medical mantra “see one, do one, teach one” can no longer be standard of care.


Simulation-based medical education has grown rapidly over recent decades, as has the body of evidence to support its use for a variety of skills and competencies. This trend has been especially evident in emergency medicine (EM) training. Once rarely utilized, many EM training programs now implement some form of simulation or manikin-based simulators and there is strong evidence to validate this practice [4]. Moreover, effective simulation builds a strong foundation of clinical skills, and has positive downstream effects on patient care and objective health outcomes [5].

Implementation of high-fidelity systems and technology in simulation have shown favorable outcomes in EM resident learning, but simulation-based resident training is not limited to highfidelity manikins or models [6]. Additional strategies, including table-top scenarios and in situ simulation, have been used to prepare for a variety of emergent scenarios including mass casualty training, hospital codes, and disaster drills. The in situ strategy has proven effectiveness in emergency departments for the development of protocols, improvement of teamwork, and provision of timely care [7].

The evidence for simulation in GME also extends to procedural skills training. There are a multitude of high acuity procedures that EM physicians must master in training, and this need only furthers the demand for procedural simulation as a key strategy in skill development. For example, relatively common procedures such as cardiopulmonary resuscitation, defibrillation, and cardiac arrest management have shown significant improvement after simulated training [8]. Reinforcing the trainee’s clinical procedure experience with simulation augments their exposure to lower frequency procedures, increases trainee success rates, and improves retention of skills [9]. Often referred to as “high frequency low acuity” procedures including pediatric intubation and transvenous pacing have also shown improved performance and mastery after a simulated curriculum [10,11]. The development of procedural skills and proficiencies via simulation has been shown to translate into improved trainee confidence and objective outcome measures [5,12].

Beyond technical skills and manikin-based teaching, simulation in EM has been successfully implemented in a variety of ways. It has proven effective in communication and health systems science [13]. It can activate learners’ emotional states, allowing them to develop cognitive and communication skills to improve their clinical practice. It can be effectively used in a virtual space to provide for remote learning opportunities, as exemplified during the COVID-19 pandemic [14]. We have also seen its use in resident remediation, allowing for performance improvement in a safe environment for both our trainees and patients [15].

At its very core, simulation allows emergency training programs the ability to address the needs of their learners. There is now a large body of evidence to demonstrate the utility of simulation in performing high-stakes procedures, caring for a variety of disease presentations, and developing team-based skills. Simulation allows mastery of these elements to be achieved under controlled conditions and in a safe environment, ultimately improving trainee performance and skill acquisition.


Despite the growing body of evidence and our specialty’s reputation for pushing the envelope, EM is not the first or even the second medical specialty to consider the codification of simulation as a required component in residency training. For example, in the United States and as outlined by the Accreditation Council for Graduate Medical Education (ACGME), both the general surgery and internal medicine specialties implemented simulation as a core program requirement as early as 2006 [16,17]. In the interval, the general surgery ACGME has expanded these requirements to include a “simulation-based curriculum,” and general surgery programs are now mandated to designate an individual who is responsible for managing these activities [18]. Although simulation within EM residencies has seen tremendous growth and substantiation in the last few decades, the ACGME does not yet include simulation as a formally required component of resident education in EM [16]. The result is considerable variety in simulation education and delivery both in the United States and internationally where simulation requirements are not formalized or clear.


With a growing abundance of high-quality evidence to support the need for simulation in GME, the time has come for medical simulation to become a standard, codified requirement in residency training. While the evidence suggests that all medical specialties would gain from inclusion of this educational format, EM residents and their patients are uniquely positioned to benefit from the adoption of this no longer novel educational strategy.

Emergency physicians are required to master a plethora of unplanned, high-stakes encounters and high acuity procedures. On any given shift, EM residents may be required to interview and examine a victim of a sexual assault or provide notification to a family member of an unanticipated death. On that same shift, time-sensitive and high-stakes procedures such as cardiopulmonary resuscitation, central line placement, and intubation may also be necessary. These encounters and procedures require a high level of competence and skill with no margin for error, and there is clear evidence that physician performance in these areas improves following simulated experiences [19,20].

Our patients deserve our best, and it is our moral imperative to deliver them the highest-quality care possible. Formalizing simulation as a core requirement in EM GME is the necessary next step.



No potential conflict of interest relevant to this article was reported.




Investigation: JDR, ADB; Resources: JDR, ADB; Writing–original draft: all authors; Writing–review & editing: CK, ADB. All authors read and approved the manuscript.


1. McLaughlin S, Fitch MT, Goyal DG, et al. Simulation in graduate medical education 2008: a review for emergency medicine. Acad Emerg Med 2008;15:1117–29.
2. Maran NJ, Glavin RJ. Low- to high-fidelity simulation: a continuum of medical education? Med Educ 2003;37 Suppl 1:22–8.
3. Graber MA, Pierre J, Charlton M. Patient opinions and attitudes toward medical student procedures in the emergency department. Acad Emerg Med 2003;10:1329–33.
4. Cook DA. How much evidence does it take? A cumulative meta-analysis of outcomes of simulation-based education. Med Educ 2014;48:750–60.
5. McGaghie WC, Draycott TJ, Dunn WF, Lopez CM, Stefanidis D. Evaluating the impact of simulation on translational patient outcomes. Simul Healthc 2011;6 Suppl(Suppl):S42–7.
6. Ilgen JS, Sherbino J, Cook DA. Technology-enhanced simulation in emergency medicine: a systematic review and metaanalysis. Acad Emerg Med 2013;20:117–27.
7. Sharara-Chami R, Lakissian Z, Farha R, Tamim H, Batley N. Insitu simulation for enhancing teamwork in the emergency department. Am J Emerg Med 2020;38:833–4.
8. Langdorf MI, Strom SL, Yang L, et al. High-fidelity simulation enhances ACLS training. Teach Learn Med 2014;26:266–73.
9. Legoux C, Gerein R, Boutis K, Barrowman N, Plint A. Retention of critical procedural skills after simulation training: a systematic review. AEM Educ Train 2020;5:e10536.
10. Wong KU, Gross I, Emerson BL, Goldman MP. Simulated airway drills as a tool to measure and guide improvements in endotracheal intubation preparation in the paediatric emergency department. BMJ Simul Technol Enhanc Learn 2021;7:561–7.
11. Klein MR, Schmitz ZP, Adler MD, Salzman DH. Simulationbased mastery learning improves emergency medicine residents’ ability to perform temporary transvenous cardiac pacing. West J Emerg Med 2023;24:43–9.
12. Wang EE, Quinones J, Fitch MT, et al. Developing technical expertise in emergency medicine: the role of simulation in procedural skill acquisition. Acad Emerg Med 2008;15:1046–57.
13. Li L, Ray JM, Bathgate M, et al. Implementation of simulation-based health systems science modules for resident physicians. BMC Med Educ 2022;22:584.
14. Nadir NA, Kim J, Cassara M, et al. Simulation-based emergency medicine education in the era of physical distancing. AEM Educ Train 2021;5:e10586.
15. Nadir NA, Hart D, Cassara M, et al. Simulation-based remediation in emergency medicine residency training: a consensus study. West J Emerg Med 2019;20:145–56.
16. Accreditation Council for Graduate Medical Education (ACGME). ACGME program requirements for graduate medical education in emergency medicine. ACGME; 2022.
17. Britt LD, Richardson JD. Residency review committee for surgery: an update. Arch Surg 2007;142:573–5.
18. Accreditation Council for Graduate Medical Education (ACGME). ACGME program requirements for graduate medical education in general surgery. ACGME; 2020.
19. Hobgood CD, Tamayo-Sarver JH, Hollar DW, Sawning S. Griev_ Ing: death notification skills and applications for fourth-year medical students. Teach Learn Med 2009;21:207–19.
20. Auten JD, Ross EM, French MA, et al. Low-fidelity hybrid sexual assault simulation training’s effect on the comfort and competency of resident physicians. J Emerg Med 2015;48:344–50.

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