Table 3.

Values, Beliefs, and Practices in Simulation and Practice

Belief	Practice
Value 1: Identifying and treating dangerous pathology is a key role of emergency physicians
A systematic approach prevents missing dangerous diagnoses	In the majority of case discussions that we observed there was a conversation around “can't miss diagnoses” and a systematic approach to test interpretation was consistently reinforced. For example, while reviewing a patient's ECG the resident taught the students a systematic approach (rate, rhythm, axis etc.), so as “not to miss anything.”
Those with potential life or limb threats take priority	Facilitators were frequently triaging patients and teaching students about that process. For example, when a new shift of students entered the simulation, the facilitator triaged the patients then allocated the first group of students to the patient with chest pain because “she is the most crucial one right now.” When students were deciding which patient to sign up for next, one of the supervisors explained triage scores (listed on the board) to them.
Identifying nonurgent diagnoses is less important and someone else's job	Supervisors avoided ordering tests that do not change ED management. While telling other staff about her experience supervising students who managed a patient with urinary retention, likely secondary to BPH, she described how the students wondered whether they should order a prostate specific antigen test then shared that “in my mind I was like %$#* NO, that's not our job…obviously I didn't say that, but I was thinking that.”
Emergency physicians feel that other specialists don't always share the same urgency for treating life‐threatening illness	When impersonating colleagues (surgeons, cardiologists, nursing homes) staff were not scripted and had flexibility to behave in any way that they saw fit. We observed that they often created delays such as “being in theater” or “I'm really busy, I'll get there when I can.” After creating delays over the phone staff would often regale each other with tales about a recent time that they “couldn't get a consultant” down to see a patient or recognize urgency of a situation. In the simulation during the case of the patient with a STEMI, the cardiologist said “look, we've got another patient on the table, it's going to be a while. Just stabilize her downstairs.” In discussion of this case during the debrief students expressed their frustration and the facilitator commiserated, “it feels like we're on our own and the patient is dying in front of us and we know what they need but we can't get it.”
Value 2: A cornerstone of emergency medicine is managing uncertainty
We can identify and manage risk to combat uncertainty	For certain presentations supervisors introduced students to decision rules to help identify risk and manage uncertainty. For example, during care for the patient with whiplash the supervisor pulled up the Canadian C‐Spine rules and went through how to use them with the students. This categorized the patient at low risk of having a C‐spine injury. They then modeled how to explain the categorization of risk to the patient and obviated the need for further imaging.
We can manage patients without all of the information	Supervisors modeled an approach of simultaneous treatment and information gathering. When students presented the case of the infant with a SVT they were particularly focused on why the infant was in SVT and wanted to know the answer to that questions before proceeding with management. The supervising physician advised that while they are unsure at this point why that is the case, they could treat it without having all the facts. She guided them through using the diving reflex to terminate the arrhythmia. After the child was stabilized, they returned to a discussion that focused on “why.”
There are not always right answers	Each case was run at least four times over the 4 days, which allowed staff involved in the simulation exercise to see how other physicians managed the same patient. There were discrepancies in patterns of practice. At one point in the pathology room, the staff reflected on the domestic violence case and how there was a range in the tests ordered, from no investigation to CT‐facial bones and CT‐A of the neck. Participants felt that this reflected the fact that there are many “gray” areas in medicine, rather than that any particular management plan was wrong.
Emergency physicians feel that other specialties are less comfortable with uncertainty	In this simulation exercise we were able to see evidence of how emergency physicians “package” data and patients to give to consultants. One supervisor said to the student “make sure that you have all of the details straight and results organized before your phone them [surgery] because they will want all that and might get mad.” When specialists were consulted early without all available information they voiced dissatisfaction over the phone that all appropriate information was not available, again liberties taken as individuals outside the design of the simulation.
Emergency physicians feel that students are uncomfortable with uncertainty	In the first cases of each session students were quite hesitant to present to preceptors without all the information (bloodwork or imaging results). They described that they felt they should have the “answer before speaking with the boss.” Supervisors often directly addressed uncertainty with students. One said, “you don't have to know exactly what is going on but you do have to have a plan.” Students noted that, “it was nice to learn phrases of reassurance and how to discuss uncertainty with patients through role‐modeling. We got see lots of words around the gray.”
Value 3: Patients and families are at the center of care
Emergency physicians care for any patient, anytime	The structure of the simulation exercise was such that patients ages ranged from newborn to elderly with a spectrum of disease from minor injury to life‐ending (see Table 2).
Social circumstances are essential to understanding illness	After students presented the case, a frequent follow‐up question from supervisors would pertain to home and social circumstances. They would spend time explaining why this context was important. It was the key aspect of a number of cases including the patient with domestic violence, patient who had overdosed, and the patient with the catastrophic hemorrhagic stroke. In the debrief the facilitator stated, during student's reflection on the importance of social circumstances, “we often are involved at the intersection of physical and social crises.”
Communication with patients is important to their experience	Supervisors spent time exploring communication strategies with students. One student was responsible for breaking the bad news to the wife of the patient with the hemorrhagic stroke. The doctor reflected that they did not use the “dying” word then spent time explaining why using direct language such as “dying” or “death” is important to avoid confusion. Supervisors role modeled challenging communication strategies, particularly for the patient with delirium showing how she could be redirected and engaged with. For example, the supervisor redirected the patient by asking a question about the doll she was carrying and was able to get her back into bed in a calm manor. About 5 minutes later the students employed a similar strategy, after initially not knowing how to interact with this patient.
Symptom management is an early priority	There was often early and liberal use of analgesia and antiemetics at the prompting of both nurses and supervisors. One supervisor explained, “while we are sorting out the diagnosis, we can treat what brought them in.”
The ED environment can be a less than an ideal setting for patients	This simulated ED faced some environmental constraints akin to an actual ED. The initial contact for the patient who was the victim of domestic violence was in the hallway, as that was the only clinical space available to see her. Both students and staff reflected during the exercise and in the debrief that this seemed inappropriate. Interestingly, supervisors were quite quick to justify this practice, while students remained adamant that there had to be a better way.
Value 4: Emergency physicians must be expert at balancing needs and resources at the systems level
Efficiency is necessary, and desired	Despite the fact there was not actually any time pressure or need for efficiency, throughout the day, supervisors balanced student autonomy with supervisor intervention. In speaking with them about the balance, we heard comments such as, “it would just be faster if I did it.” Or “I'm getting a bit inpatient and want to move on.” Some supervisors explicitly taught students how to maximize efficiency by starting a history and physical examination on a new patient while waiting for results on the first patient that they cared for. In the debrief students reflected on the fact that this was the first time that they had to “multitask” or “care for more than one patient.”
Emergency physicians should actively manage patient flow	Supervisors emphasized early decision making and identification of disposition. Students were frequently asked “do you think the patient is coming in or going home.” Supervisors then explained that early identification of disposition helps with planning for that patient and for the department, it creates “forward momentum.” The supervisors who were consultants would frequently “run the board” to see who they could move to the “clinical decision unit” or “short stay” to free up beds when they felt they were “bed‐blocked.” All this occurred despite no actual time or patient pressure.
Emergency physicians feel that other services in the hospital prohibit efficiency and efforts to manage patient flow	Students brought requisitions to the simulated pathology and radiology department and also collected results from those areas. The supervisors there would send students away saying “it hasn't been long enough” or would say phrases we occasionally hear from the laboratory such as “hmmm …we seem to have lost the requisition, can you fill another one out and come back in 10 minutes, we'll see what we can do” or “we are about to run the sample, come back in 15 minutes” or “the ESR machine is down.” After doing so the two to three supervisors would laugh and tell a story about how that happened to them recently and how it impeded their workflow in a consequential and frustrating way.
Emergency physicians must have a strong understanding of inpatient and outpatient health resources	Throughout the simulation exercise supervisors demonstrated tacit knowledge about navigating the health care system for specific needs of patients whether that be as inpatients or outpatients. This knowledge, and ability to deftly traverse health care domains, was necessary for patients to receive the care that they needed. For example, the supervisor for the patient with urinary retention shared information with students about the trial of void clinic which would be the most appropriate outpatient follow up. In conversations about identifying appropriate disposition and consultation supervisors often shared that “part of the role of the emergency physician is getting patients where they need to be.”
Value 5: A team approach is necessary to providing high quality emergency care
Emergency physicians feel that nurses are essential to the care for patients and education of junior doctors	During the debriefs the phrase “the nurse showed me ____” came up in every session. The structure of the simulation was such that nursing staff were essential teachers for the students ranging from procedural, to navigating systems, to assessing patients, to teaching about medications. At one point the nurse told a student that he should “hold off [giving anticoagulation for the patient with STEMI] until cardiology confirmed.” He advised that cardiologists often have a specific regimen that they would like emergency physicians to deliver.
Emergency physicians feel that allied health practitioners are valuable in caring for patients with complex needs	Throughout the simulation sessions the supervisors encouraged students to include allied health colleagues liberally. This included a consult to physiotherapy for a patient with back pain, consult to the social worker for the patient with domestic violence and for the patient who was dying, and contacting the coroner for the patient who died in care. When these consults were initiated the supervisors often spoke about the specific role that those professionals might play for our patients and why their role is important, particularly in more complex circumstances.
Value 6: Education is integral to emergency medicine
Lifelong learning is necessary to being an emergency physician	Throughout the simulation exercise supervisors modeled ongoing learning. Sometimes students would ask questions that they did not know the answer to and they would say, “let's look it up together” then show the students the resources they were using to do so. Behind the scenes supervisors would collegially compare the way that they managed the same case, talking about why the ordered or didn't order specific tests.
Feedback on performance is important for ongoing growth and development	In the prebrief students were instructed to ask the supervisors directly for feedback and “continue to do that throughout your career.” The suggestions that they received were to ask “how'd you think that case presentation went?” or “what could I have done better in that case?” Some of the supervisors in this case were fairly junior. Built in to the exercise was the opportunity for them to receive feedback on their supervision and teaching skills.
Simulation is a valuable educational tool	Intrinsic to the effort required to coordinate and deliver this type of large‐scale simulation is that the emergency physician coordinators believe it is a valuable educational method.
Value 7: Emergency medicine is part of self‐identity
Certain personality traits make one well suited to emergency medicine	Accountability: Students described that when they had a patient assigned to them and described as “your patient” they felt like a proper doctor. One in particular said she “got excited every time a patient was assigned.” As facilitators were discussing the debrief amongst themselves after one said, “you can just tell the students that you like and that would fit in the ED. You know, the kids that say they love being assigned a patient …” Resourcefulness: One student was caring for the patient who died. The nurse found him and asked him to declare death. I saw him go to his resource book that he brought and look up how to do it then proceed to go through the appropriate steps. His supervisor later asked how he knew what to do. When he explained that he just figured out how to solve the problem and she was very impressed. She shared his actions with many of the other facilitators who commented that he “was great.” Collegiality: Throughout the day staff modeled collegiality. Supervisors introduced themselves to medical students by their first names. They offered support by saying phrases such as, “lots of help here for you buddy.” The prebrief and debriefs helped students explore the positive, challenging, and confronting aspects of work with their peers in a supportive setting. Throughout the day supervisors relaxed with each other in the break room where they bonded over food.Enthusiasm: Supervisors and staff shared and modeled enthusiasm with students. In the prebrief the facilitator asked students, “what are you most excited about?” and when they returned to the debrief noted, “there are more smiles than when you started,” which resulted in giggles and nods from the group. Many of the supervisors were volunteering their time to be there. One supervisor, who just participated on the second day, said she, “couldn't wait to join the fun.”
Patients’ stories become part of our own	As soon as students entered the debrief room, but before the debrief formally started, they began sharing patient stories and their positioning in those stories with each other. During the debrief the facilitator asked students to share their stories. In each session, this seemed to generate a significant amount of discussion that had to finally be closed with effort from the facilitator. Stories ranged from purely clinical, to reflective, to emotive.
Emergency physicians feel that they are different than their colleagues	An ED resident was on the phone pretending to be the consulting cardiologist. After she hung up the phone she turned and joked with another ED resident that she “wasn't good at being mean, I should have been harsher.” This implied that she felt that in order to accurately portray her inpatient colleague she had to change her persona. I overheard the conversation and following interactions between the consultant surgeon (played by an ED resident) and medical students for a patient who had a perforated ulcer. Initially, I was sitting with the surgeon. I heard her being quite short with the students and asking for many investigations to be done before reluctantly agreeing to see the patient, “after I am done in the OR.” She got off the phone and said to me, “it's a bit ridiculous, you know. I was consulted without any investigations or blood work for an ulcer. It could be anything. You know, I am in no hurry to help them. That's exactly how the surgical resident would be in real life.” This brusque portrayal of a surgeon said a great deal about how emergency physicians view their colleagues and how they sometimes pride themselves in being in the trenches as opposed to on the consulting end of the phone.
Students aren't quite “us” … but they could be	Students seemed to identify and respect a hierarchy. Students were much less likely to approach consultants than residents to review cases and noted that they got nervous before talking to the “big doctor.” The facilitator in the pathology room noted that, “the signs should have been placed on the floor because that's where they [the students] all look when they're here.” In their absence, facilitators sometimes joked about students. One student called the simulated switch board and talked to a facilitator pretending to be a urology nurse from the trial and void clinic. The student said that she had “inserted a catheter and evacuated the bladder.” After hanging up the facilitator burst out laughing and repeated the word “evacuate” to a room full of other physicians. They all seemed to find great pleasure in her choice of words. At times the facilitators would refer to the students and their actions as “cute” or “adorable” referencing their naiveite. Despite the hierarchy and amusement with student behavior there was an obvious desire by facilitators to make the learning experience as positive a one as possible. This was evidenced in their actions with students throughout the day but also by the fact that they were volunteering time to be present to help with teaching in this capacity. In the debrief, students were asked how they felt being supervised by the senior doctors and nurses. Responses such as, “they were so nice” or “it's nice to know that we'll have support” were frequent. There were no negative experiences about the supervision shared during the debriefs.

The practices throughout the exercise that allowed researchers to identify these beliefs and values are only representative examples from the data set.

BPH = benign prostatic hyperplasia; ECG = electrocardiogram; ESR = erythrocyte sedimentation rate;; STEMI = ST‐elevation myocardial infarction; SVT = supraventricular tachycardia.