BACKGROUND:Relationships within the surgeon-anesthesiologist dyad may influence perioperative teamwork, safety, and efficiency, yet little is known about the perceptions and expectations these physicians hold of one another. STUDY DESIGN:We conducted a qualitative, phenomenological study using semi-structured, one-on-one virtual interviews with 20 surgeons (7 women) and 20 anesthesiologists (13 women), ages 31 to 81 years, representing 24 US states. Interviews were audio-recorded, transcribed, and coded using Dedoose version 9.2.22. After stabilization of a codebook, working in teams, investigators applied consensus coding with 100% interrater agreement and performed thematic analysis focused on perceptions and expectations. RESULTS:Surgeons frequently described anesthesiologists with whom they had difficulty as lacking dedication, continuity of care, and equal ownership of patients. Anesthesiologists frequently described surgeons with whom they had difficulty as not recognizing anesthesiologist expertise, not demonstrating expected professional respect, prioritizing operative goals over patient physiology, and exhibiting problematic personality traits. Despite these negative generalizations, both groups articulated some positive perceptions of their colleagues and shared expectations of what can be characterized as operating room professionalism, including engagement, respect, effective communication, competence, flexibility, efficiency, and prioritization of patient care. Differences emerged in emphasis: surgeons highlighted conscientiousness and engagement, whereas anesthesiologists emphasized respect for their professional expertise. CONCLUSIONS:Surgeons and anesthesiologists hold unexpressed negative perceptions and unmet expectations of one another that may influence collaboration and perioperative care delivery. Increasing awareness of these attitudes may represent a first step toward improving relational coordination, teamwork, and patient safety.

Effective approaches to acute stress management in healthcare are more urgently needed than ever, given the increasing pressures teams face, generating chronic stress, which can decrease overall baseline resilience. While these chronic stressors range from waning resources to growing medical deserts, acute sources of stress emerge from deteriorating patients, leadership or personnel crises, or rapidly developing medical innovations with increasing clinical time demands given provider coverage gaps. Traditional wellness or stress-management curricula at the undergraduate, graduate, and continuing education levels focus heavily on individual provider betterment and resilience to deal with everyday chronic stressors. However, they lack a focus on teaching specific skills to manage these acutely stressful situations, which can occur regardless of specialty. Just as elite athletes must prepare for the most stressful aspects of their careers, we should also be training with techniques to perform at our best in these moments, whether they involve a deteriorating patient, ongoing team conflict, or sudden systemwide challenges. In this article we review the case for acute stress training at all levels of education within healthcare and propose tactics from multiple high-stress disciplines, including those outside of healthcare, to fortify clinician performance no matter the circumstances.

From the 1Department of Anesthesiology, Alpert School of Medicine, Brown University, Providence, Rhode Island 2Department of Anesthesiology, Rhode Island Hospital/Brown University Health, Providence, Rhode Island 3CurbsideMD.ai, Cranston, Rhode Island. Accepted for publication January 17, 2025. Conflicts of Interest, Funding: Please see DISCLOSURES at the end of this article. Reprints will not be available from the authors. Address correspondence to Rebecca D. Minehart, MD, Alpert School of Medicine at Brown University, Department of Anesthesiology, MSHPEd, 593 Eddy St, Davol 129, Providence, RI 02903. Address e-mail to [email protected].

We consciously and subconsciously judge each other every day using demographic characteristics (such as gender and race/ethnicity), and these social identities shape our lives in profound ways. Demographic diversity impacts perioperative teams yet is poorly understood, and mixed results are reported in other team-based work settings. Drawing from decades of organizational behavior literature, the authors review their model of critical factors related to interplays between diversity, communication, and conflict, existing within a hierarchical environment influenced by power differences. Evidence-based recommendations are provided, aimed at maximizing the benefits of diversity in perioperative teams while minimizing negative consequences.

Racial inequities in maternal care persist despite decades of enhanced focus on understanding why they exist. Anesthesiologists are ideally positioned to influence Black women's and birthing people's care through their near-ubiquitous presence in many labor and delivery environments. Through intentionally addressing drivers of increased maternal morbidity and mortality, such as inequities in labor analgesia and anesthesia and postpartum pain management, anesthesiologists have a powerful role in changing lives.

Objectives: Nonlinear retrospective analytic techniques can allow for in-depth understanding of accidents and their causes, yet they are infrequently used in health care. The purpose of this study was to provide an example, using Causal Analysis based on Systems Theory (CAST) together with an inductive thematic analysis to understand the contextual factors contributing to one hospital’s perioperative safety events. Methods: We created a hierarchical control structure of the hospital’s perioperative system with input from a multidisciplinary group. We then analyzed safety events that were self-reported during a COVID surge (April 2020) using CAST to understand their contributing factors. Next, we analyzed the contributing factors using inductive qualitative thematic coding to identify system-level safety risks. We mapped each system-level safety risk to a recommendation for future mitigation. Results: We screened 122 safety reports and found 19 safety events that met inclusion criteria. The analysis revealed 245 contributing factors represented by 22 subthemes corresponding to 3 major themes: (1) vulnerable processes, being problems with workflows or communication channels; (2) personnel challenges including challenges with staff redeployment as well as cognitive and behavioural challenges; and (3) poorly designed or unavailable equipment. Each subtheme corresponded to a prevention strategy, such as creation of a central protocol hub. Conclusions: Using a nonlinear accident analysis technique together with thematic analysis, we were able to identify system-wide contributing factors to safety events. These contributing factors led to recommendations for future pandemics or crises characterized by scarce resources, limited data, and a rapidly changing environment.

e-REAL Labs is at the forefront of educational technology, pioneering the use of intelligent avatars—also known as digital humans or embodied conversational agents (ECAs)—to enhance medical training. These sophisticated AI-driven avatars replicate complex human interactions, providing real-time, personalized feedback based on behavioral and conversational cues. This article presents an applied research project developed in collaboration with the Center for Medical Simulation in Boston, showcasing an innovative approach that goes beyond traditional feedback mechanisms. By enabling reflective dialogue and interactive learning, these digital humans foster deeper understanding and skill development. As dynamic learning partners, ECAs represent a transformative shift in medical education, offering an immersive and effective method for professional training. This AI-powered approach redefines the role of feedback in healthcare education, setting a new standard for simulation-based learning and professional development.

Metaverse is a term used to describe a hypothetical shared virtual space where people can interact with a computer-generated environment and each other, and there are multiple metaverses currently being developed by various companies and organizations. Cooperation in the metaverse is at the core of the ongoing digital revolution that impacts the way we design and deliver overall education and training. Medical simulation is a powerful way to deliver education and training, based on the use of technology and other techniques to recreate clinical scenarios for the purpose of teaching and training healthcare professionals and students. This article is about how to involve learners in a metaverse within the medical simulation field. The key questions that we address are as follows: What is the metaverse today? What will it look like in a few years? How do we enhance medical simulation based on cooperation in the metaverse? How do we engage learners with diversity and inclusion?

We created a serious game to teach first year anesthesiology (CA-1) residents to perform general anesthesia for cesarean delivery. We aimed to investigate resident knowledge gains after playing the game and having received one of 2 modalities of debriefing. We report on the development and validation of scores from parallel test forms for criterion-referenced interpretations of resident knowledge. The test forms were intended for use as pre- and posttests for the experiment. Validation of instruments measuring the study's primary outcome was considered essential for adding rigor to the planned experiment, to be able to trust the study's results. Parallel, multiple-choice test forms development steps included: (1) assessment purpose and population specification; (2) content domain specification and writing/selection of items; (3) content validation by experts of paired items by topic and cognitive level; and (4) empirical validation of scores from the parallel test forms using Classical Test Theory (CTT) techniques. Field testing involved online administration of 52 shuffled items from both test forms to 24 CA-1's, 21 second-year anesthesiology (CA-2) residents, 2 fellows, 1 attending anesthesiologist, and 1 of unknown rank at 3 US institutions. Items from each form yielded near-normal score distributions, with similar medians, ranges, and standard deviations. Evaluations of CTT item difficulty (item p values) and discrimination (D) indices indicated that most items met assumptions of criterion-referenced test design, separating experienced from novice residents. Experienced residents performed better on overall domain scores than novices ( P < .05). Kuder-Richardson Formula 20 (KR-20) reliability estimates of both test forms were above the acceptability cut of .70, and parallel forms reliability estimate was high at .86, indicating results were consistent with theoretical expectations. Total scores of parallel test forms demonstrated item-level validity, strong internal consistency and parallel forms reliability, suggesting sufficient robustness for knowledge outcomes assessments of CA-1 residents.

e-REAL Labs are at the forefront of revolutionizing educational technology through the integration of intelligent avatars, also known as digital humans or embodied conversational agents (ECAs). These ECAs are advanced pedagogical tools that simulate complex human behaviors and interactions within medical training simulations. Equipped with generative artificial intelligence, the ECAs provide immediate, nuanced feedback to medical instructors, tailored to behavioral and conversational cues, thereby enhancing learning outcomes. This article is about an applied research project developed in collaboration with the Center for Medical Simulation in Boston and is about a breakthrough approach that moves beyond traditional feedback methods, offering a customizable and interactive experience that actively engages learners in dialogue and reflection on their performance. By serving as dynamic learning partners, these digital humans represent a paradigm shift in educational practice, offering an innovative, immersive way to advance professional skills in the healthcare field. This novel application of AI is not just an incremental improvement but a complete reimagining of the role of feedback in professional growth and development, with the potential to redefine how healthcare professionals engage with and benefit from simulation training.

Phenomenon: The urgency of having fair and trustworthy competency-based assessment in medical training is growing. Simulation is increasingly recognized as a potent method for building and assessing applied competencies. The growing use of simulation and its application in summative assessment calls for comprehensive and rigorously designed programs. Defining the current baseline of what is available and feasible is a crucial first step. This paper uses anesthesia and intensive care (AIC) in France as a case study in how to document this baseline. Approach: An IRB-approved, online anonymous closed survey was submitted to AIC residency program directors and AIC simulation program directors in France from January to February 2021. The researcher-developed survey consisted of 65 questions across five sections: centers' characteristics, curricular characteristics, courses' characteristics, instructors' characteristics, and simulation perceptions and perspectives. Findings: The participation rate was 31/31 (100%) with 29 centers affiliated with a university hospital. All centers had AIC simulation activities. Resident training was structured in 94% of centers. Simulation uses were training (100%), research and development (61%), procedural or organizational testing (42%), and summative assessment (13%). Interprofessional full-scale simulation training existed in 90% of centers. Procedural training on simulators prior to clinical patients' care was performed "always" in 16%, "most often" in 45%, "sometimes" in 29% and "rarely" or "not" in 10% of centers. Simulated patients were used in 61% of centers. Main themes were identified for procedural skills, full-scale and simulated patient simulation training. Simulation activity was perceived as increasing in 68% of centers. Centers expressed a desire to participate in developing and using a national common AIC simulation program. Insights: Based on our findings in AIC, we demonstrated a baseline description of nationwide simulation activities. We now have a clearer perspective on a decentralized approach in which individual institutions or regional consortia conduct simulation for a discipline in a relatively homogeneous way, suggesting the feasibility for national guidelines. This approach provides useful clues for AIC and other disciplines to develop a comprehensive and meaningful program matching existing expectations and closing the identified gaps.

(J Clin Anesth. 2023;90:111235 |https://doi.org/10.1016/j.jclinane.2023.111235) Swiftly mobilizing resources in perioperative emergencies is crucial for patient survival, with anesthesiologists typically bearing this responsibility. Recognizing the urgency, the call for help is emphasized through formalized “stat” calls. However, the timing of seeking assistance remains subjective, posing a challenge. While empirical evidence highlights blood pressure thresholds indicative of harm, ambiguity surrounds terms like “early” in crisis management. An assumption that anesthesiologists must possess all answers hinders timely collaboration, impacting patient care. Factors affecting crisis acknowledgment, especially in simulated settings, were explored among MOCA course participants. Acknowledgment, a pivotal step in emergency response, was scrutinized alongside potential differences between active participants and observers. This investigation seeks to expose vulnerabilities in ACRM implementation, guiding future studies on crisis management in perioperative settings.

In this update we explore the current applications of simulation in obstetric anesthesia, describe what is known regarding its impacts on care and consider the different settings in which simulation programs are required. We will introduce practical strategies, such as cognitive aids and communication tools, that can be applied in the obstetric setting and share ways in which a program might apply these tools. Finally, we provide a list of common obstetric emergencies essential for a program's curriculum and common teamwork pitfalls to address within a comprehensive obstetric anesthesia simulation program.

Study objective: To systematically evaluate anesthesiology resident and attending perceptions of preoperative planning conversations (POPCs) and to generate understanding for improving the educational and clinical value of this practice. Design: cross-sectional study. Setting: two large Northeastern US academic residency training programs. Participants: clinically practicing anesthesiology residents and attendings. Interventions: An electronic survey was administered to 303 anesthesia attendings and 168 anesthesia residents across two academic institutions between June and July 2014. Measurements: Survey questions addressing phone call frequency and duration, clinical value, educational value and intended purpose of POPC were administered to both groups. Chi-squared tests were used to evaluate dif-ferences in responses between groups, with p < 0.05 as statistically significant. Main results: Responses were collected from 93 attending physicians (31%) and 80 trainee physicians (48%) for an overall response rate of 37%. 99% of residents reported paging their attendings to engage in the POPC the evening prior to all operations and 95% of trainees reported almost always receiving a call back from the attending. Trainees overwhelmingly reported attendings would believe they were unprofessional or negligent if they did not initiate a POPC (73% vs 14%, chi-square = 60.9, p < 0.001). Attendings were much more likely to view the POPC as a very important tool to discuss perioperative events (60% vs 16%, chi-square = 37.3, p < 0.001) and necessary for the majority or every case (59% vs. 31%, chi-square = 13.5, p < 0.001). The majority of attendings and trainees did not find the POPC to be a very important educational tool in terms of assessing trainee knowledge base (14% vs. 6%, chi-square = 2.76, p = 0.097), discussing teaching opportunities (26% vs. 9%, chi-square = 8.5, p = 0.004), or establishing rapport (24% vs. 7% trainees, chi-square = 8.3, p = 0.004). Conclusions: Significant discrepancies exist between how anesthesia attendings and residents perceive the pur-pose of the POPC, with trainees less likely to view the POPC as having clinical value and neither group perceiving the conversation as a very useful educational tool. The results highlight the need to reexamine the value of the daily POPC as a deliberate educational practice to meet expectations of both trainees and attendings.

Many educators have lived powerful experiences that will stay with them long after the moments have passed; times they failed at something meaningful to them, the wonder of finally understanding and "cracking the code" of a very complex concept, and the curiosity of diving into a new learning topic. What makes these so impactful? This chapter explores how learning is impacted by emotional states, such that educators can consider these potent modifiers of learning. The chapter starts by defining emotion and understanding the neurocircuitry underlying the biological basis of emotion. Then, theoretical frameworks are explored for integrating the role of emotion with the learning process. Finally, the chapter considers what these theories mean for our educational approaches in healthcare.

Metaverse is a term used to describe a hypothetical shared virtual space where people can interact with a computer-generated environment and each other, and there are multiple metaverses currently being developed by various companies and organizations. Cooperation in the metaverse is at the core of the ongoing digital revolution that impacts the way we design and deliver overall education and training. Medical simulation is a powerful way to deliver education and training, based on the use of technology and other techniques to recreate clinical scenarios for the purpose of teaching and training healthcare professionals and students. This article is about how to involve learners in a metaverse within the medical simulation field. The key questions that we address are as follows: What is the metaverse today? What will it look like in a few years? How do we enhance medical simulation based on cooperation in the metaverse? How do we engage learners with diversity and inclusion?

Introduction:To adjust for the COVID-19 pandemic's rapidly changing guidelines and clinical needs, educators turned to simulation to create realistic yet safe environments for drilling and innovating various care strategies. Individually, institutions faced creating a pathway for deploying new behaviors and techniques widely across their populace.Methods:In response to this need, we rapidly developed an interprofessional teaching curriculum for safe intubation techniques and donning/doffing of personal protection equipment to anesthesiology clinicians and technicians. Participants were taught using Roussin's Zone 1 simulation techniques including coaching from interprofessional facilitators. Survey data were collected from participants.Results:Participants' confidence levels increased, with coaching and the use of simulation cited as the most useful elements of the training.Conclusions:We believe COVID-19 catalyzed many educational initiatives, and though teams drew their own roadmaps to create programs, sharing the learning from these endeavors may inform future similar situations. Lessons of stakeholder buy-in, use of multidisciplinary teams, and building a psychologically safe space can promote rapid uptake of new techniques and technologies.

The process of learning by doing within an online interactive setting – accessible by a single and simple click of the mouse, without downloads of software or other technical procedures - is highly effective and leaves learners with a memorable experience, if the experience is multiplayer, highly cooperative, and glasses-free. That is the case with the e-REAL Online experience introduced in this article, which revolves around a case of multiple injuries acting in an alpine environment. Within this scenario, the learners are challenged to recognize a situation requiring rapid intervention, communication, knowledge sharing, decision-making, and management of an unforeseen event—while taking into consideration critical contextual factors such as a lack of time, scarcity of resources and tools, and a multitude of additional impactful factors (weather conditions, broadband availability, etc.). The entire experience is based on the visual exploration of an alpine environment and on a dialogue with the patient, which is an avatar performing as a female that was injured during a hiking activity performed alone and was found by chance by an interprofessional rescue team.

How can we design engaging and effective medical education both online and on site? Extended reality (XR) is a term referring to all real-and-virtual combined environments and human-machine interactions generated by computer technology and wearables. It includes representative forms such as AR, VR, and MR, and the areas interpolated among them. MR is a domain of particular interest today: It takes place not only in the physical world or in the virtual world, but is a mix of the real and the virtual. Metaverses can be enabled by MR wearable augments. Glasses-free MR is another very interesting dimension: e-REALâ, as a MR environment for hybrid simulation and medical education in general, can be a stand-alone solution or even networked between multiple places through a link to a special videoconferencing system. Digital humans and human-sized holograms are part of the e-REAL scenarios, making this solution unique, rich, and diversified.