Training the trainers: a survey of simulation fellowship graduates.

Background Coupled with the expansion of simulation has been the development and growth of medical simulation fellowships. These non-accredited fellowships do not have a standardized curriculum and there are currently no studies investigating the simulation fellowship experience. The purpose of this study was to explore the simulation fellowship experience of graduates throughout North America and how it prepared them for their post-fellowship career. Methods A web-based survey was developed by Emergency Medicine attending physicians both of whom completed one-year fellowships in medical simulation. Prior to distribution, the survey was reviewed and tested by three simulation fellowship graduates and a PhD researcher. Feedback was integrated into the survey prior to distribution. The survey consisted of a maximum of 29 multiple choice questions including two step-logic questions and two open response questions. The survey was distributed to simulation fellowship directors in multiple disciplines and the directors were asked to forward the survey to graduates. Additionally, the Society for Academic Emergency Medicine Simulation Academy list-serve was utilized for distribution of the survey. Results The survey had 35 responses. The majority of respondents completed fellowship within the last two years (66%, 23/35). Fellowship graduates strongly agreed or agreed that their fellowship adequately prepared them for their post-fellowship simulation career (88%). Graduates report that research design/reporting (53%) and administration (18%) were areas of their fellowship curriculum that needed the most improvement. Conclusion The majority of simulation fellowship graduates agreed that their fellowship experience adequately prepared them for their post-fellowship simulation career. Graduates also felt that training in research and administration are areas that could be improved.


Introduction
Simulation is an expanding method of instruction in medical education. 1 This growth is a result of multiple factors including the effectiveness of simulation teaching methodology, [2][3][4][5][6] increasing popularity with learners, and the greater availability of simulation equipment and centers. [7][8][9] Coupled with this expansion has been the development and growth of medical simulation fellowships. 7,10 Simulation fellowships, in multiple healthcare disciplines, provide education and training so that graduates can effectively lead simulation exercises and provide administrative leadership. Instruction typically includes adult-learning theory, assessment methodology, principles of debriefing, simulation scenario design, and the utilization of high-fidelity simulators and equipment. 10 Over the last 10 years, the number of fellowships offered has increased tenfold. 10 Fellowship training offers numerous benefits. Fellowship trained physicians in other disciplines have shown improved career satisfaction, a greater number of publications, an improved likelihood of obtaining grant funding, and an easier path to academic promotion. 11 Fellowship trained physicians report feeling more prepared for their career endeavors. 12,13 Additionally, fellowship training provides the foundation for long term mentoring, essential to the success of young faculty as they establish their careers in academia. 11 Medical simulation fellows, regardless of discipline, appreciate those same benefits and have a number of unique opportunities to improve patient safety, 14,15 the quality of medical education, 16 and related research at their respective institutions.
Medical simulation fellowships are currently not accredited by the Accreditation Council on Graduate Medical Education (ACGME) or the Royal College of Physicians and Surgeons of Canada (RCPSC). The majority of these non-accredited fellowships do not have a standardized curriculum, likely leading to varied experiences by fellows. Graduates of these programs hold important roles within academic institutions and the training of these individuals as educational leaders has a substantial impact within their communities. There are currently no studies investigating the simulation fellowship experience from the perspective of fellowship graduates. The purpose of this study was to explore the experience of simulation fellowship graduates throughout North America and how the fellowship prepared them for their post-fellowship career.

Study design and participants
A web-based survey (www.surveymonkey.com) for simulation fellowship graduates was constructed and distributed electronically in the spring of 2015 to 28 simulation fellowship directors in the United States and Canada with up to four reminders in a twomonth period. The simulation fellowship program directors were asked to distribute the survey to graduates of their programs. In order to identify simulation fellowship programs, a web-based search was performed using internet based search terms including, "simulation fellowship," "medical simulation fellowship," "surgical simulation fellowship," and "anesthesia simulation fellowship." Additionally, the Society for Academic Emergency Medicine (SAEM) Simulation Academy list-serve was utilized for distribution of the survey because of the significant number of simulation fellowships based in emergency medicine. 10 The exact number of simulation fellowship graduates is unknown. However, previous scholars have estimated that there are approximately 55-60 simulation fellowship graduates as of 2015. Additionally, there are now approximately 25 graduates annually in North America. 17 At the time of this study no database of simulation fellowship graduates existed. The correspondence through the list-serve indicated that the survey was exclusively for simulation fellowship graduates. The Summa Institutional Review Board granted an exemption for this anonymous research study.

Data-collection methods and analysis
The survey was developed by two Emergency Medicine attending physicians who both completed one-year fellowships in medical simulation. Kern's curriculum development provided the conceptual framework for questions concerning the simulation fellowship curriculum including needs assessment for targeted learners, goals and objectives and evaluation and feedback. 18 In addition, the survey questions that focused on feedback, curriculum integration, skill acquisition, transfer to practice and e83 instructor training were based on McGaghie et al.'s 12 features and best practices of medical simulation. 19 Prior to distribution, the survey was reviewed and tested by three simulation fellowship graduates and a PhD researcher. Feedback was integrated into the survey. The survey consisted of a maximum of 29 multiple choice questions including two skip-logic questions and two open response questions.
Survey results were analyzed using Microsoft Excel. Frequencies, means, and ranges were calculated as appropriate. All submitted survey responses were incorporated in the analysis, including responses from incomplete surveys.

Results
The survey had 35 responses from simulation fellowship graduates; the total number of simulation fellowship graduates is unknown. Twenty-eight of the 35 responses were from simulation fellowship graduates responding to the forwarded email from their fellowship directors while the remaining seven responses were from the SAEM list-serve. Thirtythree of the 35 respondents that started the survey completed the entire survey. This resulted in 33-35 responses per question.

Post-fellowship employment
First appointment post-fellowship: 26% (9/34) of the graduates were simulation directors and 21% (7/34) were simulation assistant directors while 29% (10/34) had a non-leadership simulation faculty appointment. Of the graduates working in simulation, 46% (13/28) are simulation directors with 71% (20/28) of graduates working in university/academic simulation centers and 18% (5/28) working in community hospital affiliated simulation centers. A few of these graduates may either be working in their second appointment or did not originally secure a simulation position straight out of fellowship. While 85% (28/33) of graduates work in simulation, 29% (8/28) of these have no protected time for simulation education and therefore do not receive salary for these simulation activities.

Discussion
This survey provides a glimpse into the experiences of simulation fellowship graduates and how their fellowships prepared them for their careers. Twothirds of surveyed fellowship graduates completed fellowship within two years of the survey. This is consistent with the recent growing popularity and expansion of simulation fellowships. 10 As simulation becomes more prevalent in education, the demand for faculty with simulation training will continue to increase.
More than two-thirds of fellows completed a oneyear fellowship. However, other respondents completed a fellowship that was less than a year in length or even two years in length. The variability in the duration of simulation fellowships is secondary to the lack of a standardized curriculum for simulation fellowships. Without a consensus, curriculum simulation fellowship directors independently determine the goals, objectives and length of their respective fellowship programs leading to variations in fellowship duration and content. This variability highlights that fellowships, each with their own goals and objectives, provide a range of experiences for fellows. Fellows may choose a program that concentrates on virtual reality, educational research, or standardized patient simulation. The lack of standardization allows fellows the opportunity to focus on their own interests in this growing body of knowledge about this teaching methodology.
More than two-thirds of graduates were emergency medicine (EM) physicians. EM residency programs make heavy use of simulation education and this may lead more residents to pursue a fellowship in simulation. Additionally, emergency medicine residency programs graduate more residents than surgery or anesthesia programs. 20 During fellowship, most graduates felt they had the ability to debrief effectively with minimal guidance after 4-6 months and the majority of fellowship graduates felt they had the ability to run a highfidelity full body simulator within 3 months. This is consistent with the majority of simulation fellowship graduates who either strongly agreed or agreed that debriefing training and simulation technology training during fellowship adequately prepared them for their post-fellowship career. Debriefing, as well as simulation technology training, are vital to being an effective simulation educator post-fellowship. Without these skillsets, especially debriefing, fellowship graduates would have difficulty effectively educating learners using simulation-based medical education. These results are mostly consistent with the 2015 Ahmed survey of simulation fellowship directors, which reports that fellows typically require 4-6 months before they are able to effectively debrief or run a high-fidelity full body simulator with minimal guidance. 17 The majority of graduates felt the two biggest areas in need of improvement were research design/reporting and administration. This finding is consistent with the fact that only half of fellowship graduates reported completing of a manuscript during their fellowship. Additionally, this may contribute to the reason nearly one-third of fellowship graduates take positions that do not have any salary support. Future simulation fellowship curriculua should incorporate research and administration training to provide graduates with the tools necessary to be successful in their simulation career.
This study has several limitations. The total number of simulation fellowship graduates is unknown and while the survey was distributed to simulation fellowship directors from multiple specialties in the United States and Canada, the survey was only e86 distributed to one specialty's list-serve for simulation with a known high number of fellowship graduates (emergency medicine). 10 There is no one established list-serve for all simulation fellowship graduates. Therefore, the survey was distributed to fellowship directors to forward to their graduates. Directors who did not forward the survey limited our ability to receive data from fellowship graduates. Additionally, there is no comprehensive list of fellowship directors. Those programs that did not have an internet presence or up-to-date contact information were unlikely to forward the survey to their graduates. The generalizability of the study is limited because the survey received only 35 responses from 28 fellowship programs and one list-serve. The survey was anonymous and therefore impossible to compare the demographics of those who completed the survey to non-responders. Furthermore, the number of programs has grown since the survey, potentially decreasing the representativeness of these findings.

Conclusion
Simulation fellowships are a rapidly expanding area of medical education. The majority of simulation fellowship graduates agreed that their fellowship experience adequately prepared them for their postfellowship simulation career. However, graduates felt that training in research and administration are two areas that could be improved. This survey provides valuable information and insight into the simulation fellowship experience from the graduates' perspective.
Conflicts of interest: The authors declare they have no competing interests. The authors report no external funding source for this study.