CAEP GeMES | Does integrating patient death within simulation favor better performance from residents?

In Great Evidence in Medical education Summary (GEMeS) by Daniel TingLeave a Comment

“Success is a lousy teacher. It seduces smart people into thinking they can’t lose” – Bill Gates 

One school of thought in simulation education is that the simulated patient should never die. Instead, learners should be “rescued” before ultimate failure to prevent students from having their confidence battered by a poor outcome in simulation, which could lead to decision paralysis in a real life scenario. Another contrary line of reasoning, one of which underpins much of traditional medical teaching, is that public failure–or even occasional public humiliation–is a powerful motivator for self-directed studying and improvement. 

Often, simulation debriefs focus on improving “soft” skills such as team communication rather than comments on medical management. Strong clinicians must be experts at both. Can the use of a challenging medical case designed to overwhelm junior learners promote knowledge acquisition of medical expert topics? This “Great Evidence in Medical education Summary” (GEMeS – pronounced “gems”) was originally posted by the CAEP EWG GEMeS Team on February 20, 2015 and answers the question: “Does integrating the death of a patient within simulation favor better performance from residents?” A PDF version of the GEMeS summary is available here.

Education Question or Problem

Does integrating the death of a patient within simulated scenarios favor a better performance from residents when they encounter this situation in their future practice?

Bottom Line

Yes. Residents who experience the death of a patient in a simulated scenario are more likely to adequately manage a similar case six months after the initial exposure.


Learning through simulated independent practice leads to better future performance in a simulated crisis than learning through simulated supervised practice.
Goldberg, A., Silverman, E., Samuelson, S., Katz, D., Lin, H.M., Levine, A. and DeMaria, S.
British Journal of Anaesthesia, published online January 8 2015, pages 1-7.
doi: 10.1093/bja/aeu457
Study Design
Single-blind controlled randomized study
Funding sources
Funding provided by the Icahn School of Medicine, Mount Sinai Hospital, New York.
All R1 Residents from the Anesthesia Program of the Mount Sinai Hospital participated in the research project. The study was conducted in the Simulation Laboratory of the hospital.
Level of Learning
R1 Anesthesia Program

Synopsis of Study

To determine if exposure to a simulation during which a patient dies improves the performance of residents ultimately faced with a similar case, the 24 residents were split into two groups. In Phase 1, they were expected to manage the case of an anesthetized patient whose saturation level falls as a result of contamination in the hospital’s oxygen source. No external help was offered to the “Independent” group, as opposed to the “Supervised” group, which received the help of an anesthetist when the condition of the patient reached critical status. In Phase 2, the groups were re-exposed to a similar case six months later to assess an improvement in performance following the initial exposure. In this second phase, no external help was made available to either group.

During Phase 1 of the study, none of the residents gave the appropriate treatment to the patient.  In the “Independent” group, the patient therefore died in 100% of the cases. During Phase 2, 67% of the residents from the “Independent” group were able to manage the situation adequately vs 17% of those in the “Supervised” group. Furthermore, residents’ performance from the “Independent” group, according to the ANTS scale[1], was superior during Phase 2. Finally, the anxiety level among residents on the STAI scale[2] were similar after Phase 2, showing no particular susceptibility of experiencing mental distress in either group.

[1] Anesthetists’ Non-Technical Skills scale
[2] State Trait Anxiety Inventory scale

Why is it relevant to Emergency Medicine Education?

Medical errors can be devastating to the health team as well as to the patient–they are, however, an invaluable source of learning experience. As it is not acceptable to allow these errors to occur in the clinical practice for the sole benefit of the learners, the simulated environment offers an interesting substitute.

However, the simulated death of a patient is somewhat taboo in present practice, for fear of provoking an important level of mental distress among the learners.

This article suggests that performance of residents can be improved following exposure to the death of a patient during a simulation, without creating additional distress among the residents.

What are your preferred strategies to debrief in simulation? How can we elevate the discussion beyond rote repeating of important but basic communication tick-boxes such as closed-loop communication, role assignment, or use of names?


More About the CAEP GEMeS

This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Great Evidence in Medical Education Summaries (GEMeS) project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive GEMeS each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers.


Daniel Ting

Daniel Ting is an Emergency Physician and Clinical Assistant Professor at the University of British Columbia, based in Vancouver. He is the Editor-in-Chief of CanadiEM and a Decision Editor at the Canadian Journal of Emergency Medicine. He completed the CanadiEM Digital Scholarship Fellowship in 2017-18. No conflicts of interest (COI).
Eliane Raymond-Dufrense

Eliane Raymond-Dufrense

Eliane is a simulation fellow at Bond University in Australia. She is a recent graduate from the University of Laval EM training program and has a passion for medical education.