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- Simulation as a learning resource in medical educationPublication . Matos, Francisco José Palma Maio de; Sousa, Miguel Castelo Branco Craveiro deBackground: The use of simulation in medical education ensures improved learning and an increase in experience without the risk of real events. The absence of previous training in the execution of technical procedures may involve risks to the patient, inseparable from the technique in question. Thus, medical education is decisive in preventing medical errors, and simulation has a critical role in this field. Different approaches, such as mixed-realism scenarios, high-fidelity mannequins, and virtual reality, are used in simulation as resources for medical education. Simulation can be used to train technical and non-technical skills such as team endeavor, team communication, and clinician-patient communication. The latter, which includes the disclosure of an adverse event to a patient, contributes to the increase in the clinician's confidence. Although the recognition of simulation as a fundamental resource in medical education has been increasing in the last years, there is a lack of implemented courses, as part of pre- and post-graduate medical training, and quantitative evaluation of the impact of these courses in residency and, at ultimately, in patient care improvement. Objectives: To increase anesthesiology training's efficacy and safety by including simulation training as a mandatory component of Anesthesiology Residency. To accomplish this primary objective, the work was divided into three aims: 1) to train and evaluate, through the construction of an evaluation instrument divided into two-parts: the participation in a clinical episode that triggered an adverse event in a simulation scenario in an Operating Room context and the dissemination of the same adverse event, in a hybrid simulation scenario; 2) to design a skill training program, in a simulation environment according to the programmatic contents included in the Portuguese Residency in Anesthesiology including technical and non-technical skills; 3) to implement and evaluate the program through the construction and validation of self-assessment questionnaires answered by the residents before and after each simulation module. Results: The comprehensive methodology involving mixed-realism simulation engaged 42 Anesthesiology residents in an adverse event and its disclosure to the patient. It allowed practicing to a range of patients’ answers through the different stages of a grief response. The instruments to assess the performance and the anesthesiology residents' disclosure practice showed excellent interrater reliability and high internal consistency (p<0.05). Three-hundred and forty individuals attended the competencies training program for Portuguese Anesthesiology residents, designed according to the programmatic contents defined by the Portuguese Board of Anesthesiology: 76 from the first year, 89 from the second, 82 from the third, and 93 from the fourth and last year. For the evaluation of this program, self-assessment questionnaires to be applied before and after each simulation module were designed, and the internal consistency was tested, indicating a high internal consistency of all questionnaires. Students assessed the importance attributed to several main technical concepts in Anesthesiology, and their training and experience before and after each simulation course. The results were statistically significant in almost all comparisons (p<0.05). Likewise, these questionnaires also included questions regarding non-technical skills such as need for help, making mistakes, self-efficacy over time, need for support, communication, and team attitude. Over time, the need for support and the number of mistakes increased from the residents' perspective (p<0.001). However, the students assumed that, through the residency, there was an improvement in the communication skills since they easily expressed their opinion, even if they disagreed with the consultant anesthesiologist. Unanimity is highlighted regarding the importance of non-behavioral competencies for clinical practice excellence, identified by 4th-year residents at the end of training with simulation. Finally, the residents rated all the programmatic contents addressed during the simulation modules as highly important. The last year's topics were the ones with numerically higher importance attributed by the trainees. Conclusions: The evaluation instrument divided into two parts demonstrated solid psychometric properties to evaluate the performance of communication to the patient of the occurrence of an adverse effect. The mixed concept of reality-simulation allowed residents to be involved in an adverse event and train their communication before direct contact with a patient. The construction of a simulation program according to the Anesthesiology Residency's pedagogical contents improves training in this area without putting patients at risk. It has repercussions on recognizing the error, enriching the value of self-confidence and the fundamental role of behavioral skills.In the end, this study showed that simulation also has repercussions on the identification of gaps that must be overcome before the residents become independent, culminating in improved patient safety. Together, the results obtained emphasize the positive impact of simulation as a learning instrument of the Medical Residency in Anesthesiology.