Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contact us Login 
  • Users Online:786
  • Home
  • Print this page
  • Email this page

 Table of Contents  
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 302-305

Choosing wisely - Clinician educators' guide to high-value simulation-based education

1 Health Research Methods, Evidence and Impact and McMaster Faculty of Health Sciences Program for Education Research, Innovation (MERIT), Hamilton, Canada
2 Department of Medicine and McMaster Faculty of Health Sciences Program for Education Research, Innovation (MERIT), Hamilton, Canada

Date of Submission10-Oct-2020
Date of Decision02-Dec-2020
Date of Acceptance10-Dec-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. Sandra Monteiro
McMaster Faculty of Health Sciences Program for Education Research, Innovation (MERIT), David Braley Health Sciences Centre, McMaster University, 1280 Main Street West, Hamilton ON L8S 4L8, Hamilton
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_323_20

Rights and Permissions

Health professions' trainees and educators rely on workplace learning for much of clinical skills training. Yet, organizing, structuring, and delivering core curricular educational experiences are limited by the ad hoc nature of patient presentations, workplace complexities, and clinical pressures. The ongoing worldwide COVID-19 pandemic has exposed and magnified these challenges: trainees face restrictions in accessing workplace environments, and educational patient encounters are actively being minimized to reduce viral transmission. Simulation is an attractive option to supplement workplace learning but comes with significant material and human resource costs. Identifying situations where simulation is worth it – provides high value – and could redress curricular gaps created by pandemic restrictions is of paramount importance to curricular leads. Borrowing from the clinical world, where the Choosing Wisely campaign helps guide clinicians to avoid wasting resources while selecting high-value uses of resources, we propose a Choosing Wisely for educators to maximize the value of simulation-based education under pandemic pressures.

Keywords: Choosing Wisely, COVID-19, simulation-based education

How to cite this article:
Monteiro S, Sibbald M. Choosing wisely - Clinician educators' guide to high-value simulation-based education. Arch Med Health Sci 2020;8:302-5

How to cite this URL:
Monteiro S, Sibbald M. Choosing wisely - Clinician educators' guide to high-value simulation-based education. Arch Med Health Sci [serial online] 2020 [cited 2021 Jun 22];8:302-5. Available from: https://www.amhsjournal.org/text.asp?2020/8/2/302/304726

  Introduction Top

Learning and teaching clinical skills in the workplace are a health professions' cultural tradition.[1] Both faculty and trainees take advantage of the complex, rich clinical environment to provide core curricular training experiences. However, workplace affordances, clinical pressures, and the random nature of disease presentations and evolutions make planned education difficult. Consequently, a significant proportion of clinical skills training are ad hoc and self-directed. In other words, the best way to learn to be a clinician is by spending time with other clinicians, working directly with patients. Clearly, this is a challenging curriculum to organize or standardize.

  The Value of Simulation Top

A simulation-based education curriculum can supplement in-person clinical skills training.[2] While sacrificing some authenticity of the genuine clinical environment, simulation has the advantage of standardizing, planning, and ordering curricular experiences and allowing trainees to tackle their early learning curves without putting patients in a harm way.[3] While simulation-based education is an accepted part of any health professions' curriculum, early forays into simulation-based education were the focus of much debate. Many healthcare centers invested heavily in sophisticated simulation centers and training equipment, prompting clinician educators and scholars to question how much authenticity was required.[3],[4] Were expensive highly technical simulators truly required or could simpler materials with lower fidelity suffice[4],[5],[6] Studies revealed that expensive, high-fidelity equipment did not offer an advantage.[6],[7] In addition, the concept of functional task alignment, which encourages educators to focus on the match between learning objectives, learning outcomes, and context, quelled the debate.[4] Critically, the definition of simulation-based education was disentangled from the use of highly technical or expensive equipment. Unfortunately, the resources required to maintain an entire simulation center with staff, standardized patient training program, and even dedicated clinical rooms for peer-to-peer learning,[5],[8],[9] remain extensive and expensive.

Before 2020, that is, in a prepandemic world, faculty and trainees were less restricted in how they organized learning opportunities. For example, medical residents could teach medical students in the clinical environment and then refresh their skills in a simulated setting as well. Nursing students could refine their skills in safe, simulated settings. Developing competence in communication or collaboration could be addressed with interdisciplinary simulations or in situ training scenarios. Simulation centers in academic hospitals were routinely busy with scheduled objective standardized clinical examinations, student-led clinical skills practice sessions, interprofessional simulation training, and faculty development workshops. The frequency of these activities was acceptable at first, but financial costs and ultimately the value of simulation-based education require analysis.[10],[11] As the world is aware, an unprecedented turn of events changed the routine curriculum significantly.

Due to current health and safety guidelines, such as those offered under the Choosing Wisely COVID-19 recommendations, concern over trainee and patient safety has changed how trainees access education resources. Globally, many medical schools have modified how students and residents access clinical environments for training.[1] For example, the Canadian guidelines (https://choosingwiselycanada.org/covid-19/) list the following nine recommendations for the public and healthcare providers:[12]

  1. Do not go out for nonessential reasons. Keep a safe physical distance from others (2 m or 6 feet) and follow guidance from your national and local public health authority
  2. Do not go in-person to a hospital, clinic, or healthcare provider for routine care (preventative visits, routine blood work) or nonessential care without calling ahead
  3. Do not go to the emergency department for the assessment of mild COVID-19 symptoms. Use virtual tools or screening centers if available
  4. Do not self-prescribe or request unproven therapies to prevent or treat COVID-19
  5. Do not offer nonessential services to patients in person, if virtual tools such as telephone or online visits are available. Delay nonessential care and laboratory testing when possible
  6. Do not send frail residents of a nursing home to the hospital, unless their urgent comfort and medical needs cannot be met on site
  7. Do not give red blood cells (RBCs) based solely on an arbitrary hemoglobin level. Give one unit of RBCs at a time and reassess the need for more
  8. Do not intubate frail elderly patients in the absence of a discussion with family members regarding the patient's advance directives whenever possible
  9. Do not prescribe unproven therapies for COVID-19 patients other than in an approved clinical trial.

According to the Choosing Wisely campaign,[12] recommendations on this list were selected based on ratings of global COVID-19 safety protocols. Experts including clinicians from different specialties, patient advisors, and members of the international Choosing Wisely community contributed to an audit of available strategies.[12] Various medical experts were then invited to rate the strategies using a 5-point Likert scale measuring agreement.[12] Items achieving 80%–90% agreement (i.e., average score of 4 or 5) were retained for the Canadian guidelines.[12] Recommendations one through four are directed at the public, while recommendations five through nine are directed at clinicians. In terms of potential impact on education outcomes, recommendations one through three create limitations on the kinds of patient–trainee interactions that occur in workplace. While a lower volume of patients presenting at the emergency department is certainly a welcome reprieve for seasoned physicians, the drop in patient numbers translates to a drop in training opportunities. In addition, recommendation five, encouraging increased use of online or phone visits, eliminates opportunities to observe senior staff or trainees in practice and opportunities for novices to practice basic skills, such as capturing vital signs or taking a history. The numerous routine clinic visits, which were probably seen as repetitive, helped create a foundation of basic skills and knowledge. As a risk management strategy, strict prioritization of education resources has limited opportunities for interdisciplinary and undergraduate clinical skills training around the world.[1] Notably, there has been significant restriction applied to simulation-based clinical training, as this also carries risks of pandemic transmission between learners, faculty, and simulation specialists.

In response, existing strategies of online conference-based meetings between medical residents and staff have become more frequent.

Many have used the opportunity presented by these restrictions to innovate with new modes of simulation-based education. Simulations are managed through a hybrid of in-person staff acting out a critical patient scenario and online tools, such as breakout rooms and screen sharing to support decision-making and debriefing. However, the challenges of maintaining high-quality medical education within the restrictions of physically distanced protocols present new tensions as educators and trainees wonder about the quality of this form of education.[13],[14] While these adaptations reduce risk and permit social distancing, they press the question of how functional task alignment works within the online space. Despite these adaptations, staff members are still exposed to risk, have increased requirements for managing sophisticated audio-visual (AV) equipment (which most simulation centers already have), and still carry substantial resource implications (the simulation center, staff, AV personnel, and equipment). Considering the current increased focus on safety, how then do we replicate the bedside or clinical experience online?

Here, we take a brief look at the potential simulation and real-world solutions that may be relevant to the modified curricula in the health professions. Inspired by the Choosing Wisely framework,[15],[16],[17],[18] we take a two pronged approach: (i) identify education challenges created by COVID-19 public health recommendations and (ii) identify simulation-based education design elements that offer the highest value. Consistent with a Choosing Wisely framework, we define “highest value” as something that is low on resources or cost, while having a significant impact on learning outcomes.[10],[16] In addition, within the context of COVID-related education resource restrictions, we highlight strategies that also offer safe administration.

  Choosing Wisely in Adaptations to Simulation-Based Education Top

The Choosing Wisely campaign was launched to reduce low-value healthcare services, including unnecessary interventions and overutilization of ineffective strategies.[16]

”The origin of the “Choosing Wisely” initiative was a 2010 New England Journal of Medicine article by Howard Brody, in which he urged each specialty society to commit itself to a Top Five list that would contain tests or treatments that are “commonly ordered, are among the most expensive, and have not been shown by evidence to provide meaningful benefit to at least some major categories of patients” (Brody, 2010, 284). He urged the Top Five lists to stick to “the most egregious causes of waste.”[16]

The two-step crowd-sourcing technique described in the previous section is the basis of the Choosing Wisely campaign. [12,15-18] Relying on expert perspectives, and agreement across large samples (e.g., The Canadian COVID-19 campaign invited 293 individuals, of which 161 responded), the Choosing Wisely framework[15] addresses the much-needed balance between cost (e.g., resources, staff, financial) and benefit (e.g., time savings, patient safety, improved care). In this paper, we create an analogic guide to Choosing Wisely based on an identification of high-value simulation-based education interventions. Although these recommendations are not based on a similar crowd-sourced list of high-impact or low-cost education strategies, they are based on our collective experience and expertise in education science and the principles of functional task alignment.[4],[5],[19],[20],[21],[22]

We translate two generic safety guidelines into impact statements within health professions' education. We then respond to the impact statements with potential pedagogical approaches that take advantage of current online or virtual solutions. [Table 1] identifies the two main strategies for maintaining safety of health professions trainees: (1) reduce trainee–patient interactions and (2) reduce self-directed trainee–trainee interactions.
Table 1: Summary of the potential impact to health professions training that results from COVID-19 safety protocols and potential online, safe solutions to maintain high-value simulation-based education

Click here to view

  Conclusion Top

The COVID-19 pandemic has created a great deal of disruption to many facets of health professions education.[26] Clinical placements, clerkships, and internships in many professions have been modified significantly.[27] The lack of sufficient access to clinical contexts for training may have a lasting impact to our trainees.[13] While simulation-based education is often proposed as a supplement to clinical training and redress curricular gaps due to pandemic restrictions, safety measures have restricted access to simulation as well. Notably, simulation-based education programs have always had to balance cost and value since their introduction into the health professions.[10] The goals and processes of the Choosing Wisely campaign seem a natural fit for helping achieve this balance.

Although many trainees are now getting more accustomed to a “new normal”' and some programs may even be softening restrictions, there is a great deal of scholarship still being developed to document the many consequences, adaptations, and lessons learned from the COVID-19 pandemic.[13],[27],[28] Rather than contribute new lessons, the goal of this commentary was to offer a concise synthesis of evidence-based pedagogical principles that apply to the increasing use of simulation-based education techniques in the pandemic environment. The call for more simulation needs to balance evidence-based educational principles with practical and pragmatic strategies to keep patients, staff, and trainees safe.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Tolsgaard MG, Cleland J, Wilkinson T, Ellaway RH. How we make choices and sacrifices in medical education during the COVID-19 pandemic. Med Teach 2020;42:741-3.  Back to cited text no. 1
Zendejas B, Brydges R, Wang AT, Cook DA. Patient outcomes in simulation-based medical education: A systematic review. J Gen Intern Med 2013;28:1078-89.  Back to cited text no. 2
Cook DA, Hamstra SJ, Brydges R, Zendejas B, Szostek JH, Wang AT, et al. Comparative effectiveness of instructional design features in simulation-based education: Systematic review and meta-analysis. Med Teach 2013;35:e867-98.  Back to cited text no. 3
Hamstra SJ, Brydges R, Hatala R, Zendejas B, Cook DA. Reconsidering fidelity in simulation-based training. Acad Med 2014;89:387-92.  Back to cited text no. 4
Grierson L, Norman G, Monteiro S, Sibbald M. Simulation-based education and the challenge of transfer. In: Clinical Simulation. London: Academic Press (Imprint of Elsevier); 2019. p. 67-80. 21.  Back to cited text no. 5
Norman G, Dore K, Grierson L. The minimal relationship between simulation fidelity and transfer of learning. Med Educ 2012;46:636-47.  Back to cited text no. 6
de Giovanni D, Roberts T, Norman G. Relative effectiveness of high- versus low-fidelity simulation in learning heart sounds. Med Educ 2009;43:661-8.  Back to cited text no. 7
Walsh CM, Rose DN, Dubrowski A, Ling SC, Grierson LE, Backstein D, et al. Learning in the simulated setting: A comparison of expert-, peer-, and computer-assisted learning. Acad Med 2011;86:S12-6.  Back to cited text no. 8
Domuracki K, Wong A, Olivieri L, Grierson LE. The impacts of observing flawed and flawless demonstrations on clinical skill learning. Med Educ 2015;49:186-92.  Back to cited text no. 9
Cook DA, Andersen DK, Combes JR, Feldman DL, Sachdeva AK. The value proposition of simulation-based education. Surgery 2018;163:944-9.  Back to cited text no. 10
Petrosoniak A, Brydges R, Nemoy L, Campbell DM. Adapting form to function: can simulation serve our healthcare system and educational needs?. Advances in Simulation 3, 8 (2018). https://doi.org/10.1186/s41077-018-0067-4.  Back to cited text no. 11
COVID-19: Choosing Wisely Campaigns; 2020 Available from: https://choosingwiselycanada.org/covid-19/. [Last accessed on 2020 Dec 02].  Back to cited text no. 12
Theoret C, Ming X. Our education, Our concerns: The impact on medical student education of COVID-19. Med Educ 2020;54:591-2.  Back to cited text no. 13
Andersen SA, Cayé-Thomasen P, Sørensen MS. Novices perform better in virtual reality simulation than in traditional cadaveric dissection training of mastoidectomy. J Surg Simul 2015;2:68-75.  Back to cited text no. 14
Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA, et al. 'Choosing Wisely': A growing international campaign. BMJ Qual Saf 2015;24:167-74.  Back to cited text no. 15
Blumenthal-Barby JS. “Choosing wisely” to reduce low-value care: A conceptual and ethical analysis. J Med Philos 2013;38:559-80.  Back to cited text no. 16
Lakhani A, Lass E, Silverstein WK, Born KB, Levinson W, Wong BM, et al. Choosing wisely for medical education: Six things medical students and trainees should question. Acad Med 2016;91:1374-8.  Back to cited text no. 17
ABIM Foundation. Choosing Wisely: An Initiative of the ABIM Foundation. ABIM Foundation; 2020. Available from: https://www. choosingwisely.org. [Last accessed on November 11, 2020, Last updated on November 1, 2020].  Back to cited text no. 18
Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Med Teach 2005;27:10-28.  Back to cited text no. 19
Monteiro S, Norman G, Sibbald M, Grierson L. Adapting learning in a simulated environment. In: Clinical Simulation. London: Academic Press (Imprint of Elsevier); 2019. p. 67-80. 21.  Back to cited text no. 20
De Bruin AB, Sibbald M, Monteiro S. The science of learning. In: Understanding Medical Education: Evidence, Theory, and Practice. Digitally published by The Association for the Study of Medical Education (ASME): Wiley-Blackwell. 2018 Oct 2:23-36.  Back to cited text no. 21
Monteiro S, Sibbald M. Aha! Taking on the myth that simulation-derived surprise enhances learning. Medical Education. 2020;54(6):510-6.  Back to cited text no. 22
Tolsgaard MG, Bjørck S, Rasmussen MB, Gustafsson A, Ringsted C. Improving efficiency of clinical skills training: A randomized trial. J Gen Intern Med 2013;28:1072-7.  Back to cited text no. 23
Bjerrum AS, Eika B, Charles P, Hilberg O. Dyad practice is efficient practice: A randomised bronchoscopy simulation study. Med Educ 2014;48:705-12.  Back to cited text no. 24
Shanks D, Brydges R, den Brok W, Nair P, Hatala R. Are two heads better than one? Comparing dyad and self-regulated learning in simulation training. Med Educ 2013;47:1215-22.  Back to cited text no. 25
Hall AK, Nousiainen MT, Campisi P, Dagnone JD, Frank JR, Kroeker KI, et al. Training disrupted: Practical tips for supporting competency-based medical education during the COVID-19 pandemic. Med Teac 2020;42:756-61.  Back to cited text no. 26
Tsang AC, Shih KC, Chen JY. Clinical skills education at the bed-side, web-side and lab-side. Medical Education (Online First). 2020;?00:1-3. DOI: 10.1111/medu.14394.  Back to cited text no. 27
Marinoni G, Van't Land H, Jensen T. The impact of COVID-19 on higher education around the world. In: IAU Global Survey Report. Paris: International Association of Universities; 2020. ISBN: 978-92-9002-212-1.  Back to cited text no. 28


  [Table 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
The Value of Sim...
Choosing Wisely ...
Article Tables

 Article Access Statistics
    PDF Downloaded43    
    Comments [Add]    

Recommend this journal