Springfield, MA

Program Description
The Baystate fellowship is an internal medicine based critical care training program committed to providing excellent clinical training. Fellows are exposed to all aspects of caring for the critically ill, including medical, surgical and neurological patients in a true multi-disciplinary setting. The curriculum is constantly evolving with simulation playing an active role in teaching the various aspects of critical care medicine.

Type of Program
Critical Care

Number of Fellows in Program
4

Submitter(s) of Abstract
Program Director: Patrick T. Mailloux,DO,
Associate Program Director: Mark Tidswell, MD

Physicians caring for the critically ill require the ability to think and act quickly to correct abnormal physiology, allowing the patient to stabilize and not only survive their illness but thrive. If mistakes are made the price may be the life of a fellow human being under a doctor’s care. Critical care fellows are responsible for assessing and treating the most unstable patients in the hospital, with little margin for error, and often oversee difficult decision making with loved ones. Given the high stakes, it is necessary to develop strategies for recognizing and correcting cognitive errors with a minimization of their impact in the patient care arena. Simulation provides an opportunity for learners to develop the necessary cognitive skills for treating unstable patients in a safe, non-punitive setting.

Using high-fidelity patient simulators, we constructed an innovative, longitudinal curriculum to train first year critical care fellows in common scenarios encountered while treating an ICU patient. The initial session begins with the fellows caring for an unstable, post-operative patient arriving in the ICU after an open repair for a ruptured abdominal aortic aneurysm. The learners must choose to rapidly resuscitate the patient with large quantities of IV fluid, appropriately request and incorporate clinical information, and recognize and respond to the importance of stabilizing the patient in a timely manner. In subsequent simulation sessions, the learners must evaluate and manage the same simulated patient as it experiences typical ICU complications, including abdominal compartment syndrome, peri-operative myocardial infarction, acute renal failure, ventilator associated pneumonia, delirium, ARDS, pneumothorax, cardiac arrest and anoxic brain injury. The fellows must navigate through each issue during the respective session and make appropriate decisions to allow the patient the best chance of recovery. The final scenario involves a human actor portraying a distraught family member. The fellows must guide her through appropriate end of life decision-making. As with other simulation scenarios, learners are not coached during their discussions of decision making. If errors are made the simulated patient experiences the consequences and the fellows’ performance is evaluated during debriefing.

Further, to probe cognitive limitations, pitfalls are incorporated into each session. This educational strategy is based upon experiential learning where the fellows reflect on an experience and recognize how to conceptualize and implement important lessons into future situations. The training in the simulation center is designed to be as realistic as possible, and easily translated to the bedside in the ICU with the ultimate goal of improving patient safety and outcomes. This is a novel way for critical care fellows to acquire the skills necessary as they transition to being experts. This strategy for training our critical care fellows is in its third year and continues to evolve as we gain more experience with the process. Our most recent improvement to the simulation training is a focus on a more active role by the learner, with required reading relative to each scenario provided, a debriefing session, written exam questions and opportunity to review a video of each scenario in which the fellow participated. The efficacy of this training method is assessed via a survey of each participant at the end of the sequence, with the questions exploring their perceived overall value of the curriculum, impact on their confidence, ability to enhance their role on the ICU team, realism of the scenarios, and utility of feedback. To date, the learners view the sessions favorably and their feedback is continually incorporated into the curriculum to maximize the impact and efficiency of time spent in this endeavor.