But, did they die? A perspective on simulated patient death during training and education.

“What do you guys all think about having the patient die when you’re doing sim with your students?”

This was a question posed in a Facebook group that I, and many others follow. I scoffed in my head at the ridiculous concept of allowing such a thing to occur. Surely, everyone knows that you just don’t do that. In my time with our Education department, I was taught this by a very experienced, very well-read educator that I admire very much,“We always want our learners to end with a success”.  Secondly, it just didn’t add up to me, personally. I couldn’t think of a possible upside to this. Why discourage our learners in this way? I mean, I definitely would let the patient circle the drain if the right decisions weren’t being made or weren’t being made soon enough. If the learner wasn’t getting to where they needed to be on their own, I would insert a hint of some kind, or I would role play a staff member that would interject a piece of information that would steer the learner in the right direction.  But let the patient die? Never.

So, this is the mental model that was cemented securely in my head as I went into the comments, sure that others would echo my thoughts. Imagine my surprise when the overwhelming majority of commenters disagreed with me. The nerve!

One after another, people were sharing their viewpoints not just as Preceptors and Educators, but also their experiences as the learner.

So naturally, in my state of denial, I started Googling because “that can’t be right?”

My question was this: How would the simulated patient “death” affect the learner’s outcome?

Here are a few examples of what I found:

Impact of Unexpected Death in a Simulation Scenario on Skill Retention, Stress, and Emotions: A Simulation-Based Randomized Controlled Trial. Cureus, May 2023.

In this Canadian study, two groups of medical residents were put through cardiac arrest scenarios. In one group, the patient unexpectedly died. In the other, the patient survived.

The goal of this study was to measure and compare the retention of skills between the two groups. This was measured by bringing the groups back after three months and retesting them. Participants were measured in three different areas: Physiologic stress, Cognition, and Emotional response.  Physiological testing was completed via salivary cortisol samples. Cognition was measured via trained observers measuring and evaluating crisis resource management (CRM) during the skill scenario. Emotional response was measured via questionnaires aimed at measuring the participants’ expectations at the beginning of the exercise, and then again post scenario.

Results showed that despite measurably higher stress and anxiety levels for the group that unexpectedly experienced their simulated patients’ deaths, their retention and technical skills were not negatively affected.

Conclusion:

The authors concluded that the unexpected death of the manikin in the experimental group did not affect learning in a positive or negative manner. It did, however, result in much higher stress and anxiety levels. The authors pondered the value of this increased stress and anxiety if it did not contribute to the increased performance of the learners. Additionally, the authors had this to say.  “The unexpected nature of the death may have suggested to participants that there was a detail that they missed or something they failed to consider, meaning that in their post-scenario appraisal, they considered their resources to be insufficient to address the demands of the scenario. This suggests that the introduction of death without any clear cause damages trainees' perceptions of their preparedness.”

Next is this Meta-analysis on the subject:

The Effect of Simulated Patient Death on Learner’s Stress and Knowledge Retention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cureus, August 2023

The authors of this meta-analysis were able to focus on six studies (384 total participants) that matched their search and selection criteria. The research question they focused their analysis upon was “Does the simulated patient's death, compared to the simulated patient's survival, negatively affect the learner’s emotions and knowledge retention during a team simulation activity?”

Conclusion:

As one might imagine, results were mixed. Most of the studies did show that the learners retained information and performed better after they had experienced the increased stress of their patient’s death. Then of course, one study showed negative effects, and one more showed no difference. But it’s noteworthy that a majority of the data showed higher performance in the “they died” groups.

What I found the most interesting, and perhaps the most valuable within the text of this article, was how the authors recognized the role and skill of the facilitators in simulation training and how this affects the eventual outcomes of the learners.

The authors listed some pros to simulator death. Included are things such as experiencing death within a safe environment, the ability to reflect upon the learners’ feelings related to death, etc. However, the authors also included the cons of this. Included within that list, and perhaps the most important is that the death of the manikin can distract the learners from the main objective of the simulation, as well as “psychologically demotivate” the learner from future participation in simulation activities. I personally found that to be a pretty key concept. I mean, it makes sense, right? If the manikin dies for no apparent reason, our learners are going to walk away from that educational experience confused, stressed, and upset. It’s going to be hard to get those learners to want to engage again, and I can’t think of a single instance where that will be helpful or fruitful for anyone.

The authors shared that demotivation could come from a lack of something called case fidelity. Case fidelity is the connection between the learners’ actions and the clinical results. As an example, if the learner gives a hypotensive, hypovolemic patient an adequate fluid bolus, the patient’s blood pressure should improve. If it does not, there is a breakdown in case fidelity. This would naturally create stress and frustration for our learners. It’s within this protection of Case Fidelity where our Educators and/or Preceptors hold the key to the achievement or failure of outcomes in these scenarios.

Lastly, here is a study that used the concept of Perceived Self Efficacy to measure outcomes.

Does the unexpected death of the manikin in a simulation maintain the participants’ perceived self-efficacy?  BMC Medical Education, 2017.

  In this study, medical students were divided into two groups for a cardiac arrest scenario. One group was warned of the potential that the simulated patient could die, the other was not warned. The students’ Perceived Self Efficacy (PSE) was measured pre-test and post-test using a questionnaire. PSE is defined as “a person’s perception of their ability to carry out a task.” High PSE scores are associated with high task efficiency and competency.

Interestingly, there was no discernable difference in the two groups when measured after their respective scenarios. The groups had nearly identical amount of exposure to sudden death, clinical experience, and nearly equal amounts of training leading up to this test; strengthening the accuracy. The authors’ conclusion states “Our study helps defend the position which supports the inclusion of unexpected death of the manikin in a simulation setting.”

There are more key points that the authors include that I feel are worth mentioning.

The authors recommend avoiding scenarios where death results from an “action or lack of action by the student”. In other words, don’t make the death of the manikin the learner’s fault. Have the scenario constructed in such a way that the manikin was going to die no matter what the learner chose to do.  Additionally, they mention the importance of using experienced educators for these scenarios as well as ensuring that proper attention is given to the debriefing process. These authors defined that as a debrief that lasted “not less than 30 minutes”. This proper debrief allows space for a thorough review of thoughts and decision making that occurred during the training session.

Final thoughts:

So, what did I learn?

I learned that many programs and Educators actually do allow manikin death in simulation education, despite what I was informed as a budding Educator. I learned that though the literature is a bit mixed on whether or not it’s beneficial, there seems to be little to no harm in allowing the patient to “die”. However, the long-term effects of this experience are greatly affected by the length and quality of the post scenario debrief. Additionally, (and this will surprise no one) the skill and experience level of the Preceptor/Educator leading the debrief is the chief determinant of the learner’s perceived success or failure in the end.

Will I include death in my scenarios going forward?

Maybe. If the learning objective includes how to handle unexpected death in the real world, then I for sure would. Am I ready to allow the manikin to die even if my learner has done everything right? I’m not sure. As Preceptors and Educators it’s our job to build our people up. I want my learners to go home feeling like they’ve grown a little during the course of our time together that day. If I stumble across a way to incorporate “death” yet still feel like I am building my learner up, at least I am open to it now. I feel like I could do so without having a negative effect on the long-term retention of the skill. So that’s something, I guess?

Ultimately, it comes down to personal choice. If you think you can still build up and grow your people while still choosing the “they died” path, then go for it. There’s more than one way to build a clinician. For that, I’m grateful.

Happy teaching, Friends. Stay safe out there.

Keith

References:

1. Khanduja, K., Bould, M. D., Andrews, M., LeBlanc, V., Schebesta, K., Burns, J. K., Waldolf, R., Nambyiah, P., Dale-Tam, J., Houzé-Cerfon, C. H., & Boet, S. (May 30, 2023) Impact of Unexpected Death in a Simulation Scenario on Skill Retention, Stress, and Emotions: A Simulation-Based Randomized Controlled Trial. Cureus 15(5): e39715. doi:10.7759/cureus.39715

2. Rajendran, G., G, E., K, A., Mahalingam, S., & Krishnan, V. (2023). The Effect of Simulated Patient Death on Learner's Stress and Knowledge Retention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cureus, 15(8), e43278. https://doi.org/10.7759/cureus.43278

3. Weiss, A., Jaffrelot, M., Bartier, JC. et al. Does the unexpected death of the manikin in a simulation maintain the participants’ perceived self-efficacy? An observational prospective study with medical students. BMC Med Educ 17, 109 (2017). https://doi.org/10.1186/s12909-017-0944-x