Impact of Acute Care Physician's Age on Crisis Management Performance and Learning After Simulation-based Education
Conditions: Ageing
Sponsor: Sunnybrook Health Sciences Centre

 
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Ageing in acute care physicians Version 4.0 April 19th  2017  
Impact of acute care physician’s age on crisis management performance 
and learning after simulation-based education 
 
 
Investigators 
 
Dr. Fahad Alam, MD, FRCPC 
Anesthesiologist & Medical Education Researcher 
Sunnybrook Health Sciences Centre, Toronto, Ontario 
(Principle Investigator: Idea and protocol development, design, supervision of data 
collection, analysis, review of early draft of manuscript) 
 
Dr. Vicki LeBlanc, PhD 
Associate Professor, Faculty of Dentistry, University of Toronto 
Associate Professor, Department of Medicine, University of Toronto 
Associate Director, Wilson Centre for Research in Education, University Health Network 
& the Faculty of Medicine, University of Toronto 
Scientist, Wilson Centre for Research in Education, University Health Network & the 
Faculty of Medicine, University of Toronto 
(Co- Senior Investigator: protocol development, design, review of analysis, review of 
advanced draft of manuscript) 
 
Dr. Jordan Tarshis, MD, FRCPC 
Associate Professor,  
Department of Anesthesia 
Director, Sunnybrook Simulation Centre 
Sunnybrook Health Sciences Centre  
 
 
416-480-6100 
Jordan.tarshis@sunnybrook.ca 
(Co-Investigator: protocol development, design, review of analysis, review of advanced 
draft of manuscript) 
 
Dr. Sylvain Boet, MD, MEd, PhD 
Staff Anesthesiologist, The Ottawa Hospital 
Assistant Professor, Department of Anesthesiology, University of Ottawa 
(Co- Senior Investigator: Contributed to idea and protocol development, supervision of 
data collection, analysis, and review of manuscript) 
 
Dr. Dominique Piquette, MD, FRCPC, MSc, MEd, PhD 
Staff Physician, Department of Critical Care Medicine 
Sunnybrook Health Sciences Centre  
Assistant Professor, Division of Critical Care Medicine, University of Toronto  
 
 
Dominique.piquette@sunnybrook.ca 
(Co-Investigator: protocol development, design, review of analysis, review of advanced 
draft of manuscript) 
 
 

 
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Abstract 
 
Background: The proportion of ageing acute care physicians (ACP) (critical care, 
emergency, anesthesia) in North-America has been steadily increasing. Ageing influences 
some physicians’ clinical abilities and patient care. ACP are required to excel in crisis 
resource management (CRM) and function at a high cognitive level in a rapid paced 
environment. CRM is an essential skill that can be learned through high-fidelity 
simulation. However, there is a knowledge gap on the effect of age on CRM skills and 
simulation learning.  
 
Objective: This study aims to 1) investigate the impact of ACP ageing on CRM skills 
and 2) assess whether ageing influences CRM learning from high-fidelity simulation. We 
hypothesize that (i) in ACP, baseline CRM performance will decline with increasing age 
and that (ii) age will negatively impact CRM learning after simulation-based education. 
 
Methods: This will be a prospective multi-center trial. Seventy participants will 
individually manage a simulated crisis (pre-test) to assess the baseline effect of age on 
CRM skills. After an instructor-led debriefing, another simulated crisis (immediate post-
test) and a third simulated crisis (retention post-test) three months later. All scenarios will 
be video-recorded and rated by blinded raters using validated tools. Regression analysis 
will be performed to determine the effect of ACP’s age on baseline performance and 
learning.  
 
Significance: This study will be the first prospective trial to delineate the effect of ageing 
on CRM performance and learning in a simulated setting. The results will help shape 
national policy regarding practice assessment and help tailor continuing medical 
education. 

 
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 Background 
 
Physician demographics  
 
The proportion of older acute care physicians (ACP) has been steadily increasing.1 
Within Canada, approximately 32% - 39% of anesthesiologists are over the age of 55. A 
recent survey of members of the American Society of Anesthesiologists in 2013 revealed 
that a greater percentage of members are older (>55) in 2013 compared to 2007. These 
numbers are similar for emergency and critical care physicians where the proportion of 
the workforce over 55 is also 33-40%.2 This shift in the demographics may be explained 
by various factors. It can partially be attributed to the recent economic crisis leading to 
delayed retirement. Also, in the early 1990s, there was a reduction of residency positions, 
likely explaining the smaller population of middle aged ACP and hence, increasing 
demand for the older population to meet the needs of the healthcare system.3,4 Recent 
studies have also reported an overall shortage of healthcare providers of all ages with 
conditions varying by region. This is another reason for a greater number of older ACP 
currently working, as it calls upon delayed retirement of the older physicians to meet the 
demands of the healthcare system secondary to this shortage.5-7 
 
Consequences of Ageing 
 
Acute care specialties such as critical care, emergency medicine and anesthesia, require 
for its providers to both excel at technical and non-technical skills and function at a high 
cognitive level in a fast paced environment that requires quick decision-making and 
problem solving. Ageing in itself is associated with physiological changes, which in turn 
can influence a physician’s clinical abilities and decision-making. Stress impacts the 
ageing physician to a greater extent with potential consequences on performance, and the 
prevalence of stress, illness, fatigue, and dementia increases as one ages.3,8-11 Manual 
dexterity can also be affected with the onset of arthritis and alterations in visual acuity.3,12  
Siu et al. looked at anesthesiologists’ performance on a simulated airway emergency 
requiring cricothyroidotomy and found that operator age and years from residency were 
associated with decreased proficiency.5 Similarly, the time required for processing 
information is prolonged and decision-making can be compromised in physicians as they 
age.8,10,11,14  
 
Research investigating how such ageing-related physiological changes affect clinical 
performance and patient safety is lacking.12,15 It has been postulated that ageing 
physicians compensate through experience and pattern recognition of crises they have 
managed during their practice.13,14 However, Duclos et al. found that older surgeons had 
an increased rate of patient complications after thyroid surgery.16 The litigation data, over 
10 years, of Anesthesiologists in British Columbia, Ontario, and Quebec, show that those 
older than 65 have 1.5 times the risk of being found responsible for litigation compared 
with those aged less than 51 and the settlement were generally larger.14,15 Disciplinary 
incidents involving physicians are likely to occur later in practice, increasing with each 
10-year interval since first getting their license.14,15,17 Moreover, the degree of injury 
identified in the claims of older physicians was of greater severity.14 

 
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Crisis resource management and the ageing physician 
 
Crisis Resource Management (CRM) skills are essential clinical skills within acute care 
specialties, and are vital for patient safety. In addition to technical skills (e.g. 
defibrillation, drug preparation, intubation), a rapid and organized approach to non-
technical, cognitive skills such as decision-making, task management, situational 
awareness and team management are needed for successful CRM. High-fidelity full body 
mannequin simulation-based education is effective for learning CRM, including transfer 
of skills from the simulated setting to the clinical setting and improving patient 
outcome.4,18 However, there is a gap in the literature on whether physicians’ age 
influences baseline CRM performance and also learning from simulation-based education. 
 
Simulation and the ageing physician 
 
Although the effectiveness of high-fidelity simulation-based education has been studied 
extensively in junior learner populations (students, residents, fellows), there are a limited 
number of studies investigating its effectiveness in teaching CRM in the ageing physician 
population.19 In fact, a recent systematic review looking at the role of simulation in 
continuing medical education in ACP supported that there is limited evidence supporting 
improved learning.20 However, it is being recommended as a training, regulation and 
assessment tool for practicing physicians.12,21 
 
Simulation fidelity adds to its effectiveness. Increasing fidelity relies on three 
components: physical (actual OR environment), functional (how actions and 
consequences match the real-world) and psychological (how engaged the learners are 
with the simulation).22 The first two components can be manipulated by the simulation 
provider and equipment but the psychological component is highly dependent on the 
learner. Ageing physicians likely did not train with mannequin-based simulation 
compared to their younger counterparts and might have a preconceived bias against such 
technology. In fact, a survey on the barriers of simulation based education found that staff, 
compared to trainees, had less experience with simulators, found it less relevant for their 
current training, and perceived more barriers.23 Hence, older physicians might not be 
fully committed to, or believe in the practice of mannequin-based simulation, thus 
reducing fidelity and its effectiveness.  
 
Objectives and hypotheses: 
 
The goals of this study are to: 
1) Investigate whether ageing has an effect on baseline CRM skills of ACPs, 
(emergency, critical care, anesthesia) using simulated crisis scenarios and 
2) Assess whether ageing influences learning from high fidelity simulation.  
 
We hypothesize that: 
1) ACP baseline simulated CRM performance will decline with increasing age,  

 
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2) Although all ACP performance will improve at the immediate post-test, 
increasing age will be negatively impact the retention of CRM skills 3 months 
following a high-fidelity simulation-based education session. 
 
Methods 
 
Study Design 
 
This study is a prospective cohort multicenter study. Ethical approval will be sought from 
the Ottawa Health Science Network Research Ethics Board & Sunnybrook Research 
Ethics Board (Toronto, Canada). Written informed consent and a confidentiality 
agreement will be obtained from all participants. ACP from the academic affiliated sites 
of both universities will be recruited, with data collection being conducted locally in each 
city. 
 
Recruitment and orientation 
 
Practicing emergency, critical care and anesthesia staff with a minimum 5 years of 
practice post residency will be approached for participation.  
 
The participants will take part in three 8-minute simulated crisis scenarios based on 
current Advance Cardiac Life Support (ACLS) guidelines for pulseless electrical activity 
(PEA) arrests. The scenarios will serve as pre, immediate post and retention tests. These 
scenarios will be identical for pediatric anesthesiologists, however the “patient” in the 
scenario will be of 15 years of age, rather than an adult. Although all three scenarios will 
ultimately result in PEA arrests, each will have a unique inciting event and these will be 
randomly assigned. Participants will be unaware as to which scenarios they will be asked 
to manage. All scenarios will be recorded. Confederates will serve as the patient’s nurse 
and respiratory technician to be directed by the participant, but they will not provide tips 
or guidance in terms of how to manage the crisis.  
 
A standardized structured orientation session will be held for all participants. During this 
session, the principles of simulation-based education will be discussed and the 
participants will be exposed to the simulation room, all equipment and simulators. Since 
participants will likely have various types of previous simulation experience, each 
participant will be familiarized with the simulator by participating in an introductory non-
crisis scenario that will not require crisis resource management skills. The scenario will 
be an induction of general anesthesia using a rapid sequence induction (a common 
technique for the three acute care specialties in this study). Participants will also complete 
two questionnaires collecting demographic data (Appendix A), quantifying previous 
simulation and crisis management experience, and a life expectancy questionnaire online 
to calculate their “health age”.  The online questionnaire consists of questions that 
evaluate physiological and lifestyle factors contributing to one’s “health age” and will 
calculate a person’s “health age” based on responses.  The participant will record their 
health age on the demographic questionnaire (Appendix A).    
 

 
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Scenarios 
 
Each participant will then manage a PEA arrest scenario (pre-test) and then be debriefed 
on their CRM skills by a trained facilitator for 20 minutes. They will then manage 
another crisis scenario (PEA arrest once again, but with a different inciting event) as an 
immediate post-test. Three months after completing the instructional session, participants 
will return to manage a third PEA arrest scenario, which will serve as a retention post-test 
in additional to completing a retention questionnaire (Appendix D). The retention post-
test can be completed up to 6 months following the initial pre-test.  All three scenarios 
will be designed with the same clinical scenario that is common to all ACPs but the 
physical simulation environment will be set-up according to their specific specialty (i.e. 
ICU, OR, and ER) so that they are familiar with their unique layouts. All debrief sessions 
will be recorded as a quality control measure to ensure that all debriefs are conducted in a 
consistent manner. 
 
Simulation Scenario Development 
 
The core concepts pertaining to CRM skills and subsequent management of PEA arrest 
will be consolidated by the principal investigators and then sent out to three faculty acute 
care physicians (one from each specialty involved) from Universities not involved in the 
recruitment, who are trained ACLS instructors, for review and revisions. Once core 
concepts are agreed upon, the three simulation scenarios will be developed. Each scenario 
will then be piloted before recruitment.  
 
Outcome measures: 
As our primary outcome, we will assess the relationship of age with: 
A) CRM skills, as measured by (Appendices B & C): 
a. Ottawa GRS scale total score (non-technical CRM skills)24  
b. official ACLS checklist for PEA (technical CRM skills)25 
B) Learning* from high-fidelity simulation based education, as measured by 
change in performance (Appendices B & C): 
 
1) official ACLS checklist for PEA25,  
 
2) Ottawa Global Rating Scale for CRM24   
* Learning defined as improvement in performance in the simulation based crisis 
scenarios. 
 
Two raters blinded to the study hypotheses and the scenarios order (pre vs immediate 
post vs retention post-test), will evaluate the videos using the above validated tools.  
 
Statistical Analysis and Sample Size Calculation 
 
To test the first hypothesis, a multivariate regression analysis will be performed, with age 
as a predictor and outcomes A (listed above) as the dependent variables. To test the 
second hypothesis, a second multivariate regression analysis will be performed with age, 
pre-test score, post-test scores and their interactions (age x pre-test score, age x 

 
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intervention, age x pre-test score x intervention, and pre-test score x intervention) as 
predictors, and outcomes B on the retention test (listed above) as the dependent variables.  
 
To adequately power our study, we will need at least 10 participants per predictor 
variable entered into the analysis. In order to collect a meaningful sample, we will aim to 
recruit 10 participants per 10 year age group (<45, 45-54, 55-64, 65+), equaling 40 ACP.  
To account for attrition, we will aim to recruit 70 participants total across both sites.  
 
Timeline 
 
This study will run for 2 years:  
Ethics Submission: 
 
 
 
Months 1-3 
Content Development & Pilot Scenarios:  
Months 3-4 
Data Collection:  
 
 
 
Months 5-15 
Statistical Analysis:   
 
 
Months 16-17 
Manuscript & Dissemination of results:  
Months 18-24 
 
Dissemination Strategy 
 
Upon completion of this study, the results will be presented to educators and clinicians in 
the local Departments of Anesthesia, Critical Care and Emergency Medicine for further 
discussion in addition to providing an opportunity for other educators to explore the 
creation of a continuing education curriculum within their practice groups. Initially, this 
will be done at a local level during medical rounds presentations and seminars at the 
Universities of Toronto and Ottawa. We will submit our study for publication in peer 
reviewed medical education journals to reach a broader audience. If possible, we will 
publish the manuscript as open access to increase its citations. Applications to regional 
and international conference presentations will also by entered. Finally, we will approach 
provincial and federal regulation bodies such as the Royal College of Physicians and 
Surgeons of Canada to 1) open discussion for further studies building on our results and 
2) develop strategies for continuing education. 
 
Implications 
 
This study will be the first prospective trial to delineate the effect of ageing on CRM 
performance and learning in a simulated clinical setting. As such, the results will help 
shape not only national policy regarding practice assessment, and help develop 
continuing education for ageing physicians. The results can also serve as foundation for 
research in specialties other than acute care. Similarly, in the very least, whether ageing 
influences CRM skills or not, this study can serve as a template for investigation in non-
acute care specialties as well. 

 
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References 
 
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N, Chandra DB, Joo HS: High-Fidelity Simulation Demonstrates the 
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2010:1doi:10.1213/ANE.0b013e3181ee7f4f 
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Daugherty L, Fonseca R, Kumar KB, Michaud P-C: An analysis of the labor 
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Baxter AD, Boet S, Reid D, Skidmore G: The aging anesthesiologist: a 
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Tessler MJ, Shrier I, Steele RJ: Association between Anesthesiologist Age 
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Alam A, Khan J, Liu J, Klemensberg J, Griesman J, Bell CM: Characteristics 
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Duclos A, Peix J-L, Colin C, Kraimps J-L, Menegaux F, Pattou F, Sebag F, 
Touzet S, Bourdy S, Voirin N, Lifante J-C: Influence of experience on 
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sectional multicentre study. BMJ 2012; 344:d8041–1 
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Khaliq AA, Dimassi H, Huang C-Y, Narine L, Smego RA: Disciplinary 
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Boet S, Bould MD, Fung L, Qosa H, Perrier L, Tavares W, Reeves S, Tricco 

 
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AC: Transfer of learning and patient outcome in simulated crisis resource 
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Marinopoulos SS, Dorman T, Ratanawongsa N, Wilson LM, Ashar BH, 
Magaziner JL, Miller RG, Thomas PA, Prokopowicz GP, Qayyum R, Bass 
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Steadman RH: Improving on Reality: Can Simulation Facilitate Practice 
Change? Anesthesiology 2010; 112:775–6 
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Curtis MT, DiazGranados D, Feldman M: Judicious use of simulation 
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Appendices  
 
Appendix A – Demographic Questionnaire 
 
Appendix B – Ottawa Global Rating Scale 
 
Appendix C – ACLS (PEA) Checklist 
 
 
 

 
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Appendix A: Demographic Questionnaire 
 
Age: 
 
Sex: 
 
1. Number of years practicing your specialty (Anesthesia, Critical Care, 
Emergency Medicine) since residency 
 
0 – 10 
11 – 20 
21 – 30 
31 – 40 
41 – 50 
>50 
 
 
2. Are you, or have you ever been an ACLS Instructor? 
 
Yes 
No 
 
 
3. What percentage of time have you managed ACLS crises in your practice? 
 
0 – 10 
% 
11 – 20% 
21 – 30% 
31 – 40% 
41 – 50% 
>50% 
 
 
4. A) How many times have you experienced Full Body Mannequin Simulation 
(# of Scenarios): 
 
0 – 5 
 
6 – 10   
11 – 15 
 
16 – 20  
>20 
 
 
B) Please indicate the type of scenarios managed (check all that apply):  
 
ACLS 
Procedural 
    Rare Cases (ie MH)           Crisis Resource Management  
 
 
 
Please go to www.projectbiglife.ca.  to complete the Life Expectancy 
Questionnaire.  
 
Write the reported Health Age below: 
Health Age:  

 
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Appendix B - Ottawa Global Rating Scale Evaluation Tool 
 
 

 
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Appendix C – ACLS (PEA) Checklist 
 
 
 
 
 
 
 

 
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Appendix D – Retention Questionnaire 
 
1. Since the initial SIM session, have you had to manage an ACLS crisis? 
 
Yes 
 
No 
 
 
2. If yes, how many ACLS crises have you managed since the initial SIM 
session? 
 
N/A 
 
 
0 – 3  
4-9 
 
10-20  
>20 
 
 
3. Since the initial SIM session, have you received ACLS 
certification/recertification training? 
 
Yes 
 
No 
 
 
4. If ‘No’, will you undergo ACLS certification/recertification training soon? 
 
N/A 
 
 
Yes 
 
No 
 
 
5. I enjoyed the SIM experience 
Strongly  
Agree  
Undecided 
 
Disagree 
Strongly  
Agree 
 
 
 
 
 
 
 
 
Disagree 
 
 
6. SIM is useful for teaching and learning 
Strongly  
Agree  
Undecided 
 
Disagree 
Strongly  
Agree 
 
 
 
 
 
 
 
 
Disagree 
 
 
7. SIM is useful for assessment and evaluation 
Strongly  
Agree  
Undecided 
 
Disagree 
Strongly  
Agree 
 
 
 
 
 
 
 
 
Disagree 
 
 
8. I want increased access to SIM 
Strongly  
Agree  
Undecided 
 
Disagree 
Strongly  
Agree 
 
 
 
 
 
 
 
 
Disagree