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Simulation Fellowship

Authors

Scott Pasichow, MD, MPH
Resident, Department of Emergency Medicine,
Alpert Medical School of Brown University

Thomas Yang, MD
Resident, Department of Emergency Medicine,
FIU Herbert Wertheim College of Medicine
Aventura Hospital and Medical Center

Faculty Editor

Antoinette Golden, MD
Assistant Professor, Department of Emergency Medicine
Assistant Professor FIU Herbert Wertheim College of Medicine
Director of Emergency Medicine Residency Simulation, Kendall Regional Medical Center

Special thanks to our 1st edition writing team

Antoinette Golden, MD
Leo Kobayashi, MD, FACEP
Scott Pasichow, MD, MPH

INTRODUCTION

Description of the specialty
Medical simulation is an educational technique that can bridge gaps within traditional education and training approaches through the safe, structured fostering of medical knowledge, decision-making, procedural skills, teamwork, and communication.1 Health care simulation as a specialty is guided by 4 main purposes: education, assessment, research, and patient safety.2 Simulation can be as extensive as virtual reality surgical simulators for fine technical skills, computer-based avatars and virtual patients for decision-making skills, or as straightforward as using actors with standardized patients for communication skills. A key component of this method of teaching is to promote safe learning environments where technical and non-technical clinical skills can be taught, assessed, and reviewed with participants in order for them to apply the lessons learned and skills acquired to real patient care.2

Currently, simulation is formally used in most core health care fields (e.g., emergency medicine6, internal medicine10, OB/GYN11, surgery, and anesthesiology12 training programs) and by the full spectrum of medical professionals, including medical and paramedical providers9, nurses and nursing assistants8, physicians, and advanced practice providers7, among others. The broad applications of simulation have led to an increase in the number of simulation centers in the United States, with more than 1,000 as of 2016.12

History of the specialty/fellowship pathway
Simulation as a method of training has been documented since the 6th century, but the most direct antecedent of simulation for modern medical education lies in aviation.13 U.S. military aviation accidents in the 1930s led to the armed forces' acquisition and deployment of flight simulation trainers to decrease the frequency of these disasters.14 In the clinical realm, CPR training mannequin development followed in the 1960s, and the importance of these devices to train people in potentially lifesaving CPR skills was the catalyst for modern medical simulation.14 Simulation in medical education advanced rapidly after the Institute of Medicine's 1999 report, To Err is Human, outlined the value and need for interdisciplinary training to improve patient care and safety. The 1990s saw the rise of simulation-focused conferences14, and the 2000s were the starting point for simulation fellowship training programs across the United States and internationally. The Society for Simulation in Healthcare, an international organization supporting the community of interprofessional simulation educators, was formed in 2004.

Why residents choose to follow this career path
Health care simulation is a field for those interested in the intersection of patient care, medical education, systems improvement, and technology.

How do I know if this is right for me?
Someone interested in a career in simulation education should anticipate working with learners at different training/practice levels (e.g., undergraduates, professional students, active clinicians, and experts) from a variety of disciplines across numerous settings (e.g., community practice, hospital-based, medical, and nursing schools).

Someone interested in simulation education should be ready to serve as an educator, as well as an administrator. This can mean involvement with institution-wide committee strategic planning and small-scale operational management (e.g.business plans, cost analysis, and budgeting) to ensure proper functioning and stability of the center.15

Career options after fellowship
Simulation is a rapidly expanding, new field with many career opportunities. Many new or expanding simulation centers seek faculty for administrative, education, or research positions at junior and senior levels. For this reason, many former fellows from simulation fellowship programs are now simulation center directors across the country. Graduates may be offered academic/educator positions at an established institutional simulation facility or newly established training positions in traditional and/or emerging fields and specialties.

In general, a career in medical simulation will primarily involve direct education and hands-on training of learners, along with curriculum creation and implementation for different disciplines, experience levels, and needs. Moreover, there are individuals working in private industry (e.g., educational companies, technology companies, and insurance companies) as simulation center directors and health educators.16

Splitting time between departments
EM-based simulation fellows usually split their time between their simulation work and emergency medicine clinical duties. While some programs require their simulation fellow to work as an emergency physician in an affiliate site, other programs require participation only in simulation education related activities, with optional clinical duties17; some facilities offer observational fellowship arrangements without clinical duties.

Academic vs. community positions
Depending on the setting, responsibilities, learner cohort, and curricula will vary. Some simulation centers will be more focused on credentialing, task training, and team training, and others will devote a considerable amount of time to graduate medical education, medical student training, and/or research. These distinctions, however, are not based solely on community versus academic training affiliations, as evidenced by the creation of a validated national simulation curriculum by the Veteran’s Affairs Health System.13

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
As of early 2016, there were at least 30 U.S. programs offering fellowships in EM-based medical simulation.17,18 For details including contact information, visit the EMRA Simulation Committee website. Programs include:

Differences between programs
Simulation fellowships vary in their curricula, background and needs of learners, extent of research and administrative opportunities, and options to obtain certification or an advanced degree. Some programs will strongly emphasize research, employ a strict fellowship curriculum, have a specific cohort of learners, and/or offer advanced degree(s) or certification opportunities, etc.

Length of time required to complete fellowship 
Fellowships range from 1-2 years, with a typical start date of July 1. Most 2-year programs encourage or require the pursuit of advanced degrees, such as a Master's in Education. Moreover, programs may provide funding for a Certificate of Teaching and Learning with a concentration in health care simulation (egthrough the MGH Institute for Health Professions26 or participation in the ACEP teaching fellowship).

Skills acquired during fellowship 
The skills developed during fellowship will vary depending on the focus, requirements, and the exposure provided by the program. The knowledge and skills acquired during fellowship will likely be a combination of curriculum development expertise, technical skills, appropriate task trainer and/or mannequin utilization, moulage application, debriefing techniques, academic research methods, the fundamentals of simulation program administration/operations, etc. Graduating simulation fellows should be able to coordinate and conduct simulation courses, capably operate high-fidelity simulators, perform reliable and meaningful learner assessments, debrief proficiently, and have been reported to do so the majority of the time halfway through fellowship.20

Typical rotations/curriculum
Most simulation fellowship training programs focus on teaching skills, educational theory, curriculum development, simulation center logistics, and research.17,26,28

The majority of education occurs experientially through planning, coordinating, organizing, participating in, leading, and debriefing simulation activities; receiving feedback from faculty members and simulation technicians; and participating in operations meetings. Programs may incorporate in situ simulation within their fellowship curricula, which involves coordinating and implementing a simulation inside the hospital or affiliated clinical setting.

Board certification afterwards? 
There is no American Board of Medical Specialties (ABMS) board certification process for simulation; however, the Simulation Society in Healthcare (SSH) offers accrediting standards for simulation centers and examinations for simulation educator certification at basic and advanced levels. These certifications are the Certified Healthcare Simulation Educator programs. (http://www.ssih.org/Certification/CHSE) Additionally, there are multiple fellowships that provide certificates or master's degrees in medical education through a variety of academic affiliated institutions.

Average salary during fellowship 
Salaries during fellowship may vary each year, based on applicant post-graduate year and/or fellowship program funding.

PREPARING TO APPLY

How competitive is the fellowship application process?
As there is no universal match process for simulation fellowships, there are limited data regarding their fill rate.19 A survey of 9 programs revealed that 78% of them had a 100% fill rate for the past 3 years.

Requirements to apply
Although there are no specific or standardized academic requirements, per se, many simulation fellowships may require a description of your teaching and research background and future goals within your cover letter.17,18 Additionally, some programs will require acceptance into an advanced degree program prior to application or expect the applicant to enroll in a master’s degree program upon acceptance into fellowship.19,38

Research requirements
Research relevant to the application may include ongoing studies, projects undergoing data analysis, or manuscripts in preparation. If you have not performed simulation research, you may be able to reference medical education projects, simulation cases or curricula, or medical teaching experiences.

Suggested elective rotations to take during residency
There is no requirement for simulation rotations prior to fellowship application, but electives at your home institution in simulation or education may help to support your application for a simulation fellowship. Fellowship programs commonly offer a 2- or 4-week elective in their simulation center,26 but these are generally not advertised. One can be arranged by directly contacting the simulation center or fellowship director. Participating in this type of elective increases your exposure to simulation, broadcasts your investment and interest in the educational modality, and introduces you to potential programs of interest.

Suggestions on how to excel during these elective rotations
If you choose to participate in a simulation rotation, you can excel by being enthusiastic and engaged in the rotation, meeting and exceeding elective expectations, proactively engaging in simulation sessions, and participating in the development and implementation of simulation curricula and research programs. Prior to beginning the rotation, discuss with the director his or her expectations: which activities he or she thinks you would benefit from participating in; if they want you to write and/or program a case; with whom they would like you to work. During your elective, you may help run a program from behind the scenes.

Should I complete an away rotation?
Away rotations may familiarize you with potential programs, show your commitment to a geographic area, or provide you with simulation-related methods and experiences that you may not have been previously exposed to.

What can I do to stand out from the crowd?
In a survey among simulation fellowships, directors reported research methodology and scholarly writing as the most desired competencies (57% and 48%, respectively).20

Should I join a hospital committee?
Your home institution may have simulation committees, simulation interest groups, or other educational/training entities that host simulation events, and being active in these venues will provide opportunities to enhance your application. Participating in committees that address CPR, cardiac arrest, credentialing, quality management, and patient safety may be especially helpful in exposing you to the interdisciplinary nature and collaborative efforts associated with institutional simulation efforts.

Publications other than research
In addition to research publications, there are several other ways to generate academic deliverables. You can develop and implement a simulation case at your institution, which can be submitted to the AAMC's MedEdPORTAL. You can work with faculty or fellows to develop a simulation-enhanced curriculum (e.g. for toxicology or procedural training). After implementation, consider submitting the project as an abstract to a regional or national conference. If your institution hosts regional or national simulation workshops, volunteer to assist.

How many letters of recommendations should I get? Who should write these recommendations?
Simulation fellowship programs typically request 2-3 letters of recommendations during the application process18; many programs request one from the applicant's program director.18,40 Others specify letters of recommendation from the applicant's clinical department, medical education faculty, and/or simulation professionals.18,41

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Fellowship programs typically accept board-eligible or board-certified emergency medicine residency graduates. If you have worked as an attending, you are likely eligible for the fellowship. How competitive you are as a candidate will depend on your teaching and assessment background, academic and research work, personal qualities, and letters of recommendation, similar to a pending residency graduate.

What if I’m a DO applicant?
Some programs accept DO candidates only if they have completed an ACGME-accredited emergency medicine residency18,29,56; other programs accept DO candidates without ACGME accredited training. Contact the fellowship program's coordinator or director for clarification.

What if I’m an international applicant?
There are several programs that accept international applicants if no qualified U.S. citizens apply.17,18 At a minimum, international applicants are required to demonstrate appropriate English language abilities and be able to obtain a work visa (H-1B or J-1) or have U.S. resident status/citizenship. Non-clinical (observational) simulation fellowships may have alternative arrangements.

APPLICATION PROCESS

How many applications should I submit?
The number of places you should apply to depends on the geographic area you are interested in (and the number of programs within those geographic areas). There has been no standard recommendation published and there is a dearth of data to specify the precise number of fellowship programs to be applied to.

How do I pick the right program for me?
Assess each program with respect to how well it matches your simulation interests, academic and career objectives, and personal goals. Consider the history of the fellowship, length of the program, simulation and clinical environments, exposure to different types of learners, simulation faculty, fellowship curriculum, research support, work schedule, and other lifestyle factors.

Common mistakes during the application process
It is important to follow each program’s specific application requirements. Make sure to read each program’s application directions and inquire when specific requirements are not listed or readily accessible. Proofread your CV and cover letter multiple times prior to submitting your application to each program. Address any gaps during residency or time spent after residency prior to fellowship application. Ensure your cover letter is directed to the program to which you are applying and the header lists the correct recipient’s name and information. Submit your application before the listed deadline; if the deadline is rolling, consider submitting in September through October to have adequate time for the program to review and potentially extend an offer to interview. The simulation community is small; always speak positively about any other programs or centers that may be mentioned during the interview process. Follow up your interviews with an appreciative email or letter and include any follow-up questions. 

Application deadlines
The application timeframe for simulation fellowships varies widely. Some programs begin accepting applications as early as July 1st, with deadlines as early as September 1st and as late as May 1st. Some programs have fixed application deadlines, with interviews offered only after all applications are received, whereas others accept and offer interviews and positions on a rolling basis.

Tips for writing your personal statement
Many programs would like to know about your professional interests, career goals, what attributes you bring to the program, and why you are interested in their particular program. Be specific; you want to emphasize your unique qualifications that make you a good candidate for their fellowship position. Illustrate your experiences in simulation and how they demonstrate your dedication to the field. Moreover, you want to describe your ultimate goals upon graduating from their simulation fellowship.

Most importantly, you want to keep your cover letter professional and well-written. Use spell-check. You may even want a non-medical person to review the letter for simple grammatical errors. Have a mentor or residency program director review the letter prior to submission.

Is this a match process?
No.

What happens if I don’t obtain a fellowship position?
Most fellowship programs offer positions from October through January. If you do not receive a fellowship offer, you should continue to apply for other fellowships or other positions as an emergency physician.

INTERVIEW PROCESS

How do I stand out from the crowd?
Prior to your interview day ensure that you are well-rested. If provided your interview schedule, review the faculty included in your interview day; knowing something about their history or research will give you topics to discuss during the interview. Prepare questions to ask each interviewer. Be knowledgeable and ready to speak of/elaborate on any information listed within your curriculum vitae and cover letter. Avoid asking questions that you can find on their website or previously provided information.

What types of questions are typically asked?
Many interviews will start with, “tell me about yourself.” Be ready with a quick spiel introducing yourself to the interviewer. This can include your hometown, medical school, and residency. You can briefly describe your interest in simulation and how you pursued it during residency; the synopsis could be rounded out with a discussion of your specific interests and how they fit into their simulation fellowship program.

How many interviews should I go on?
There is limited information regarding the number of interviews that a medical simulation fellowship applicant should schedule. You should consider the number of positions offered by each fellowship, if there were unmatched fellows in previous years, and the competitiveness of your application. We suggest you attend three to five interviews to increase your likelihood of a fellowship offer.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Levine A, DeMaria Jr. S, Schwartz A, Sim A. The Comprehensive Textbook of Healthcare Simulation. 2nd ed. New York, NY: Springer New York Heidelberg Dordrecht London; 2014.
  • Riley R. A Manual of Simulation in Healthcare. New York, NY: Oxford University Press; 2008.
  • Palaganas J, Maxworthy J, Epps C, Mancini M. Defining Excellence in Simulation Programs. St. Louis, MO: Wolters Kluwer; 2015.

Important skills to practice while in residency to prepare for fellowship
The most important and relevant skill to develop for a simulation fellowship during residency is excellence in the clinical setting. Do not underestimate the value the rest of your training will have on your simulation career. For example, the more you know and understand with regard to the performance of clinical procedures, the better you will be able to break down the skills in a meaningful way to effectively help novices learn them and experts master them.

Tips on how to succeed as a fellow
Part of your time in fellowship will most likely be dedicated to a project, with a goal of publication. However, not everyone is able to publish following fellowship, and a potential lack of mentoring combined with limited time in the program can affect this outcome.44 Who your mentor is may be more important than the topic of the project.45 Keep these in mind as you select a program to ensure that you choose one with a lot of mentorship, as well as one that has experience in completing and publishing fellowship projects.

While there is not yet strong evidence regarding factors associated with a successful simulation fellowship, there are many general advice articles from other medical and surgical fellowships.46-47 These articles recommend choosing programs with areas of focus aligned with your career goals46, obtaining formal training in research methods, and ensuring you are the lead researcher and first author on your fellowship research project.47 It has also been suggested that fellows develop and pursue research questions that may become more feasible over time, and are vigilant of and apply for funding opportunities within and outside of your department.47

Success in fellowship will also be based upon experiences you have had in simulation training. The larger the variety of simulation modalities you experience, and the higher the quality of those experiences, the easier it will be to adopt them into your own simulation scenarios in the future.

CONCLUSION

Additional resources

National organizations

Conferences

  • Annual Association for Simulated Practice in Healthcare Conference
  • Annual Association of Standardized Patient Educators Conference
  • Australian Simulation Congress
  • Dutch Society for Simulation in Healthcare
  • International Meeting on Simulation in Healthcare
  • International Pediatric Simulation Symposia and Workshops
  • Meeting of the Society of Europe for Simulation Applied to Medicine
  • Ontario Simulation Exposition
  • Simulation Technology and Training Conference
  • SAEM Annual Meeting

How to find a mentor

The best place to start is at your own institution. Talk to the people who run simulation education sessions for your residency program. If you are at a medical school, you can also talk to the people who run the standardized patient encounters. Look into who runs the Advanced Cardiac Life Support classes or nursing education, as they may know of someone who has done simulation leadership training. Anyone who has gone through a simulation fellowship or who is now in a leadership position in simulation will be a great resource to guide you through the process and to give you opportunities to explore the field and determine if this is right for you.

You can also reach out to the SAEM Simulation Academy, the EM Section of the Society for Simulation in Healthcare (SSH), or the EMRA Simulation Committee. Many of these groups have members who are willing to help mentor residents as they explore this new and exciting field.

Sources

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