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Challenges in implementing simulation-based training programme in managing sick surgical patients in India: A review
Correspondence to AKSHAY KUMAR; akshay2111@gmail.com
[To cite: Singh R, Saurabh G, Bhat R, Fahad S, Vindal A, Madhavan S, et al. Challenges in implementing simulation-based training programme in managing sick surgical patients in India: A review. Natl Med J India 2025;38:284-93 DOI: 10.25259/NMJI_310_2023]
Abstract
Background
Formal skill-based critical care competency development for non-anaesthetists or non-intensivists is variable in India at the undergraduate and postgraduate levels. This review aims to understand the barriers to the implementation of a simulation-based acute critical care course (ACCC) for clinicians.
Methods
We reviewed published articles that consist essentially of qualitative data, although some quantitative data is also included. For the stratification of articles, three instruments were used for the critical appraisal of published literature: (i) Guba’s four parameters, (ii) ConQual rating and (iii) critical appraisal of the study programme.
Results
To effect a change in enabling clinicians to manage deteriorating patients safely, it is crucial to equip them with the necessary skills (technical and non-technical). It is important to introduce simulation-based courses, such as ACCC, to enable undergraduate and postgraduate medical and surgical trainees to gain the right balance of competence and confidence in managing complex situations before specialists, who are experts in critical care, take over.
Conclusion
An executive decision made by those at the helm of medical training and monitoring is necessary in medical education at both the undergraduate and postgraduate levels. The regulatory authorities (National Medical Commission and State Medical Councils) have a responsibility to address a plethora of challenges in the implementation of a scientific approach to simulation-based training. Life-saving skill development, rather than lecture-based education, is the key to equipping all clinicians in managing patients who are at risk of dying.
INTRODUCTION
Surgical residents in India are not formally trained in simple principles of applied physiology. The development of resuscitation skills at the undergraduate level is variable, and critical care is largely inaccessible to most patients who must self-pay, as reported by Prayag.1 Naeem and Montenegro suggested that a prompt and well-rehearsed scientific approach is of paramount importance in saving an unstable surgical patient from deterioration, in contrast to ineffective and costly ‘last-minute heroic’ interventions in intensive therapy units.2 The ATLS (Advanced Trauma Life Support) Subcommittee highlighted that critical care training did not exist in India either at the undergraduate or postgraduate levels.3 If surgical trainees can be trained in skills based on applied physiology, they can identify and manage unwell patients in a timely manner.4–6 The entrance examination for postgraduate courses in India focuses on ‘knowledge’ domain and to some extent on assessing ‘how to use knowledge’. However, the exit examination entails testing not only the ‘knowledge’ domain and ‘how to use knowledge’ but also assessing ‘clinical and procedural skills’ (technical as well as nontechnical) in the simulated setting to a lesser extent.
It has been reported that there has been a persistent gap between the demand and supply of critical care facilities in India.1 To manage sick surgical patients safely, surgeons should be able to save them from a domino effect of single organ failure resulting in multiorgan failure. Validated and certified skills should be integral to surgical training in India, as they are in the UK.7–9 Surgical critical care is an inseparable part of surgical training, as defined by the American Board of Surgery.10
Competence in both technical and non-technical (human factors) skills is crucial for providing adequate care to sick surgical patients, which is currently lacking in India. Moreover, there is a considerable variation in the quality of training at the undergraduate and postgraduate levels in India. Although the National Medical Commission of India mandated the creation of skill centres for both undergraduate and postgraduate training, except for a few centres, simulation-based skill development (in acute as well as elective settings) is largely still in its infancy in India.
There is ‘inherent resistance to adopting newer modes of medical training’ in India. Furthermore, an initiative taken by foreign consultants is often perceived as: ‘What is the motive of these foreign doctors trying to impose a different system.’ There is uncertainty regarding the success of leadership initiatives to introduce simulation-based training in India. We aimed to identify the range of hurdles in implementing a simulation-based critical care course for skill development.
METHODS
Search questions, as described in the first column of Table 1, were used to find published articles through various search engines, including MEDLINE, Scopus, Cochrane, Google Scholar, Discover, and the University of Liverpool Repository. Many abstracts and articles included in the numbers in the last two columns of Table 1 have covered more than one search question. Table 2 presents the Population, Intervention, Control, and Outcomes framework of the search process.
| S. No. | Search question | Number of articles in Scopus | Number of articles in Google Scholar (years 2010–2020) | Abstract read from MEDLINE, Scopus, Cochrane, Google Scholar, Discover (n=488) | Articles referenced here (n=43) (does not include cross-references, n=7) |
|---|---|---|---|---|---|
| 1. | Critical care training for surgeons in India | 42 349 | 30 200 | 33 | 2 |
| 2. | Critical care training for clinicians in India | 42 380 | 57 400 | 47 | 14 |
| 3. | Simulation-based critical care training for clinicians in India | 42 911 | 8 840 | 51 | 5 |
| 4. | Measuring the qualitative research process | 57 157 | 17 800 | 13 | 7 |
| 5. | Qualitative literature appraisal tool | 10 149 | 21 900 | 34 | 8 |
| 6. | Technical skills in critical care training | 47 403 | 31 600 | 48 | 3 |
| 7. | Human factors in critical care training | 57 741 | 28 000 | 57 | 4 |
Many abstracts and articles were common to the output when various search engines were used
| Population | Surgical trainees and interns in India, specifically, and around the world in general |
| Intervention | Education or training in critical care setting Simulation-based training in developing critical care skills |
| Control | Historical |
| Outcomes | What kind of training is available for skill development necessary for managing critically ill patients and what types of challenges are there in implementing skill development |
Inclusion criteria for literature search
Exclusion criteria for literature search
|
|
Methodology of critical appraisal of qualitative articles
We included published articles that consist of data analyzed using quantitative, qualitative, or mixed methods. Thematic analysis has been used for the interpretation of qualitative data to (i) identify, analyze, and report patterns of responses and behaviour and (b) to find patterns of clinical performance in acute care settings. Rather than relying on numbers, qualitative research records the narrative (as it unfolds in their own words), capturing impressions, views, and opinions. Qualitative research involves collation of the information that has been collected as a natural experiment to gain insight into a research question.11 Majid and Vanstone describe a range of tools that can be used in analyzing the quality of qualitative articles.12 In this analysis, we used three tools to assess the quality of articles and strength of evidence:
Adopting the technique of critical appraisal based on the list of features described by Guba and Lincoln (1990)13 and then adopted by Yilmaz.11 We used 4 parameters to ‘appraise’ the qualitative studies based on the principles by Guba and Lincoln:13 Dependability (internal validity), transferability (external validity), credibility (true value) and confirmability (objectivity or neutrality), respectively, in third, fourth, fifth and sixth columns of Tables 3 and 4. Schou et al. describe 6 features of confirmability (score range 0–6) and 5 of transferability (score range 0–5), and each of those articles has been scored accordingly14
In the ninth column of Tables 3 and 4, we have assessed articles using the ConQual score, which considers 2 of Guba’s parameters: dependability (score range 0–5) and credibility (score range minus 4–0). The rankings of various publications can be as per ConQual rating: High, moderate, low and very low
We have used the Critical Appraisal Skills Programme (CASP) tool to assess the quality of each article included in this analysis, as used by Blackburn and Yeowell.15 In our appraisal of published literature tabulated in Tables 5 and 6, we have added one more column by adding all the affirmatives out of a maximum count of 10 when using CASP as a tool. We discarded any article with a CASP score of <6. The following questions were kept in mind when analyzing articles using the CASP tool in Tables 5 and 6.
| Study | Type of study | Credibility (−4–0) | Transferability (0–5) | Dependability (0–5) | Confirmability (0–6) | Number of subjects/objective/primary end-point/motivation for inclusion or exclusions | Outcome | ConQual rating: High, medium, low, very low |
|---|---|---|---|---|---|---|---|---|
| Aliet al.16 | Evaluation questionnaires- based observational cross-sectional study | –1 | 4 | 4 | 6 | An instructor course for 20 instructor candidates and a provider course for 23 trainees was conducted. Rating of three modules: Communication skills, patient safety and clinical scenarios. | Trauma resuscitation training in rural settings would optimize trauma resuscitation training | High |
| BajwaandKaur17 | Expert opinion and review of literature (level 5 evidence) | –3 | 3 | 2 | 2 | How can coordinated care from a team of obstetricians and intensivists improve outcomes | Enhanced antenatal care, timely recognition and referral of critically ill-patients and cohesive coordinated management by maternal foetal medicine specialists or obstetricians and intensivists, the maternal mortality rate | Low |
| Divatia and Jog18 | Editorial. Level 5 evidence. | –4 | 2 | 3 | 5 | In 2012, critical care was recognized as an independent specialty by the Medical Council of India | In ICU beds in India, the focus is on revenue generation | Low |
| Divatia et al.19 | Observational cross-sectional study | –1 | 4 | 3 | 5 | Four-day point prevalence study included 4209 patients from 124 ICUs | High proportion of terminal discharges, self-paying patients and inadequately equipped hospitals in India | Medium |
| Dandona20 | Special report on prevalence and demography disease burden | –2 | 3 | 2 | 2 | Secondary data were collated and analysed. There are gaps in data identified by authors. | State-wise disease burden demonstrates increasing need for trauma care and other emergencies | Very low |
| Goldacre et al.5 | Survey by mailed questionnaires Question was: How well the doctors felt that they were prepared for their house job | 0 | 2 | 3 | 4 | 5330 doctors were mailed. 3446 replied: 67% women, 59% men. Limitation: It describes perceptions rather than performance. | 32.0% (978) agreed; 22.5% (689) neither agreed nor disagreed; 29.7% (908) disagreed; and 11.6% (354) strongly disagreed. Conclusion: Emphasis should be on skill development. | High |
| ATLS Subcommittee3 | Special report. Level 5 evidence, commentary by an expert | –3 | 5 | 4 | 4 | High applicability for training techniques using simulation in trauma resuscitation. | India is one of 60 countries for ATLS training. However, it is not compulsory part of training | Low |
| Obermeyer et al.21 | Systematic review of 95 reports | –2 | 2 | 3 | 5 | Patient outcomes and demographics as well as facility and provider characteristics of emergency care in low- and middle-income countries 192 facilities in 59 countries. | High patient loads and mortality, particularly in sub-Saharan Africa, few of these providers had specialist training in emergency care. | Medium |
| Peter et al.22 | Observational prospective cross-sectional study in ICU in India. | –1 | 4 | 3 | 5 | 499 ICU episodes. Mean APACHE-II score was 13.9 and 86% were ventilated. Direct (medical and non-medical) and indirect costing data collected. | Daily costing=US$ 2818. 33% subsidy is required. Alternate financing strategies are urgently required. | High |
| Prayag1 | Level 5 evidence, commentary by an expert | –3 | 5 | 4 | 4 | Opinion: Critical care in India is thus at the crossroads of development. | Poor critical care infrastructure in India | Very low |
| Say et al.23 | Series of cases (level 4 evidence) |
–2 | 3 | 3 | 3 | A series of near-miss obstetric cases who were at risk of lethal obstetric complications were utilized to examine the quality of obstetric care. | Maternal near-miss concept provides a key contribution to improving the quality of obstetric care | Medium |
| www.theguardian.com/global- development/24 | News report-video | –4 | 5 | 4 | 5 | Level 4 evidence | Investment into health care is crucial | Low |
This table describes the objective of the studies and inferences of each of those studies and quality of qualitative studies. This table describes the quality of qualitative studies. This stratification by CASP is an interesting comparison to the quality assessment of the same articles as performed by CASP as shown in Table 4 ICU intensive care unitCASP critical appraisal of study programme
| Study | Type of study | Credibility (−4–0) | Transferability (0–5) | Dependability (0–5) | Confirmability (0–6) | Number of subjects/objective/primary end-point/motivation for inclusion or exclusions | Outcome | ConQual rating: High, medium, low, very low |
|---|---|---|---|---|---|---|---|---|
| Sokhal et al.25 | Prospective interventional study | 0 | 5 | 3 | 5 | 24 interns participated in the course. Immediate, post-course, quantitative and qualitative feedback was taken online. Thematic analysis was used to identify, analyse and report the patterns of responses and behaviour. | Average score for utility of the course was 4.7 and for skill stations was 4.6 on a scale of 0–5. Implementing the ACCC needed simulation, interactive discussions, role play, feedback and reflective exercises that form the basis of a range of educational principles. | High |
| Kumar et al.26 | Prospective interventional study | −1 | 3 | 2 | 3 | Communication skills are taught using role play models and simulation. Live feedback is critical in learning during this course as per principles of adult learning. Interns were asked 3 weeks after ACCC to assess whether they were able to make use of this training in their day-to-day clinical practice. | ‘Role play’ to teach communication skills is effective and superior to lecture-based teaching. | High |
| Kumar et al.27 | Editorial | −4 | 3 | 3 | 2 | ACCC for clinicians – Why, What and How? | Competency development by skill-based learning is the need of the hour. ACCC has been conceptualized, developed, implemented and fine-tuned to achieve these objectives. | Low |
| Kumar et al.28 | Short communication of intervention | −3 | 3 | 3 | 4 | Medical and nursing staff in a tertiary care ED are always over-stretched and over-burdened. The entire episode takes about 2–3 minutes. The care provider should ideally return within 15–20 minutes for another brief episode of communication with the patient’s family to update them about the progress or lack of it. |
Short burst of six-step structured protocol based on SPIKES model is effective for breaking bad news to the family. | Medium |
| Bhalala and Khilnani29 | Review of Literature | −3 | 5 | 3 | 4 | To discuss advances in paediatric critical care training in India and its future directions. | Simulation has played a key role in disseminating paediatric critical training in India. | Low |
| Frengley et al.30 | Self-controlled randomized crossover study design with blinded assessors | 0 | 5 | 3 | 5 | The effectiveness of a simulation-based intervention on improving teamwork in managing airway and cardiac crises and compared with case-based learning on scores for performance. 40 teams each with a medic and two nurses were assessed. | A mix of simulation-based learning and case-based learnings is an effective teaching strategy. | High |
| Gupta et al.31 | Pre- and post-workshop self-evaluation survey was used | −1 | 5 | 4 | 4 | 50 residents were tested for an overall satisfaction score and personal comments were assessed to rate the performance of this study. A pre- and post-simulation survey. | Technical and human factor skills are taught and assessed more reliably using simulation that provides controlled and safe environment. | High |
| Goldacre et al.5 | Survey by mailed questionnaires Question was: How well the doctors felt that they were prepared for their house job | −1 | 2 | 3 | 4 | 5330 doctors were mailed. Total of 3446 replied: 67% women, 59% men. Limitation: It describes perceptions rather than performance. | 32.0% (978) agreed; 22.5% (689) neither agreed nor disagreed; 29.7% (908) disagreed; and 11.6% (354) strongly disagreed. Conclusion: Emphasis should be on skill development. | Medium |
| Jones et al.32 | Observational study using secondary data | −2 | 4 | 4 | 4 | 24 of 110 hospitals who had met service contributed to data. Limitation: Secondary and incomplete data | The introduction of MET in ANZ reduced ICU admissions secondary to a ward cardiac arrest. | Low |
| Mercer et al. 33 | Electronic questionnaire- based survey | −1 | 4 | 3 | 4 | 79 post-fellowship anaesthetic trainees were asked attributes of an ‘ideal’ anaesthetist and how these can be acquired by simulation | Simulation-based training would meet the training needs of senior anaesthetic trainees in regard to learning rare events and in real-life like situations | Medium |
| Naeem and Montenegro2 | Review includes 13 publications on MET | −2 | 5 | 4 | 5 | Physiological changes often go unrecognized. Relevant to the key question: Effectiveness of training and MET? | MET achieved 17%–26% reduction in cardiac arrest and 22%–36% reduction in mortality. | Medium |
| Smith and Poplett34 | Observational cross-sectional study | −1 | 3 | 3 | 5 | Knowledge of basic aspects of acute care was assessed amongst a group of 185 trainee doctors at six hospitals. | Improved knowledge of non-ALERT senior house officers. Limitation: Not a test of skill. | High |
| Smith and Poplett6 | Interventional cross-sectional study | −1 | 3 | 4 | 6 | Knowledge of basic aspects of acute care amongst 118 senior house officers, 36 of whom had previously attended an ALERT course, was assessed. Limitation: Skills not assessed. | Doctors’ knowledge of acute care can be improved by courses such as ALERT. | High |
| Shah et al.35 | Interventional study to assess technical competence and human factors using 46-point checklist. | 0 | 5 | 4 | 6 | Four fellows attended 15 training sessions using high-fidelity simulation. Then, video-recorded to see if this got translated to real-life patient encounters. | Simulation-based training is an effective approach to train fellows in urgent endotracheal intubation. | High |
| Tissingh et al.36 | Special report | −4 | 3 | 3 | 3 | Personal views | Simulation-based courses are a key component of surgical training | Very low |
| White and Garrioch4 | Interventional cross-sectional study | −1 | 3 | 4 | 6 | Relevant to the key question: Does training help? Limitation: Not a test of skill |
Critical care courses address the deficiencies in the knowledge of acute care of medics | High |
| www.absurgery.org/default.jsp?examoffered_scc10 | Reports and guidelines for training | −4 | 5 | 4 | 4 | Level 5 evidence | Surgical critical care is an inseparable part of surgical training | Very low |
| www.rcseng.ac.uk/education.9 | Reports and guidelines for training | −3 | 5 | 4 | 4 | Level 5 evidence | Surgical critical care is an inseparable part of surgical training | Very low |
ACCC Acute critical care courseMET Medical Emergency TeamED emergency departmentCASP Critical appraisal of study programme This table describes the quality of qualitative studies. This stratification by CASP is an interesting comparison to the quality assessment of the same articles as performed using CASP rating as shown in Table 6
| Study | Aims | Method | Design | Sampling | Data collection | Reflexivity | Ethical | Data analysis | Findings | Value | Score out of 10 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Aliet al.16 | Y | Y | Y | Y | Y | ± | Y | Y | Y | Y | 9 |
| BajwaandKaur17 | Y | ± | N | Y | ± | Y | Y | N | Y | Y | 6 |
| Divatia and Jog18 | Y | Y | ± | ± | Y | Y | ± | ± | Y | Y | 6 |
| Divatia et al.19 | Y | ± | Y | N | Y | N | ± | Y | Y | Y | 6 |
| Dandona20 | Y | Y | Y | Y | Y | N | Y | Y | Y | Y | 9 |
| Goldacre et al.5 | Y | Y | Y | Y | ± | Y | Y | ± | Y | Y | 9 |
| Mishra and ATLS Subcommittee3 | Y | ± | ± | Y | Y | Y | Y | Y | Y | Y | 8 |
| Obermeyer et al.21 | Y | ± | N | Y | Y | N | Y | N | Y | Y | 6 |
| Peter et al.22 | Y | Y | Y | Y | Y | N | Y | Y | Y | Y | 9 |
| Prayag1 | Y | ± | N | Y | Y | N | Y | N | Y | Y | 6 |
| Say et al.23 | Y | ± | Y | Y | Y | Y | ± | Y | Y | Y | 8 |
| www.theguardian.com/global-development/24 | Y | ± | N | Y | Y | Y | Y | N | Y | Y | 7 |
CASP Critical appraisal of study programme
| Study | Aims | Method | Design | Sampling | Data collection | Reflexivity | Ethical | Data analysis | Findings | Value | Score out of 10 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Sokhal et al.25 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10 |
| Kumar et al.26 | Y | Y | ± | Y | Y | Y | Y | Y | Y | Y | 9 |
| Kumar et al.27 | Y | ± | N | Y | ± | Y | Y | N | Y | Y | 6 |
| Kumar et al.28 | Y | ± | N | Y | ± | Y | Y | N | Y | Y | 6 |
| Bhalala and Khilnani29 | Y | ± | N | Y | Y | Y | Y | N | Y | Y | 6 |
| Frengley et al.30 | Y | ± | Y | Y | Y | Y | Y | Y | Y | Y | 9 |
| Gupta et al.31 | Y | Y | + | Y | Y | Y | Y | Y | Y | Y | 9 |
| Goldacre et al.5 | Y | Y | Y | Y | ± | Y | Y | ± | Y | Y | 8 |
| Jones et al.32 | Y | Y | N | Y | Y | N | ± | Y | Y | Y | 7 |
| Mercer et al.33 | Y | Y | ± | Y | ± | Y | Y | Y | Y | Y | 8 |
| Naeem and Montenegro2 | Y | Y | ± | Y | Y | Y | Y | ± | Y | Y | 8 |
| Smith and Poplett34 | Y | Y | ± | Y | Y | Y | Y | Y | Y | Y | 9 |
| Smith and Poplett6 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10 |
| Shah et al.35 | Y | ± | Y | Y | Y | Y | Y | Y | Y | Y | 9 |
| Tissingh et al.36 | Y | ± | ± | Y | ± | Y | Y | N | Y | Y | 6 |
| White and Garrioch4 | Y | Y | Y | ± | Y | Y | Y | Y | Y | Y | 9 |
| www.absurgery.org/default.jsp?examoffered_scc10 | Y | ± | N | Y | ± | Y | Y | N | Y | Y | 6 |
| www.rcseng.ac.uk/education9 | Y | ± | N | Y | ± | Y | Y | N | Y | Y | 6 |
CASP Critical appraisal of study programme. This table describes the quality of qualitative studies. This stratification by CASP is an interesting comparison to the quality assessment of the same articles as performed using two other instruments Guha’s and by ConQual rating as shown in Table 5
Was there a clear statement of the aims of the research?
Is a qualitative methodology appropriate?
Was the research design appropriate to address the aims of the research?
Was the recruitment strategy appropriate to the aims of the research?
Was the data collected in a way that addressed the research issue?
Has the relationship between the researcher and participants been adequately considered?
Have ethical issues been taken into consideration?
Was the data analysis sufficiently rigorous?
Is there a clear statement of findings?
How valuable is the research?
A stepwise approach to selecting and excluding relevant articles is shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram (Fig. 1).
- Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram outlining the search strategy and selection process
RESULTS
Current status of critical care in India and the need for investment in training
The analysis of published literature, of the current status of critical care in India suggests that formal training of residents in their ability to provide critical care is lacking. Therefore, there is a need to invest in critical care facilities and in providing ‘skill-based training’ (Tables 3 and 4).16–24
Simulation-based training in developing skills necessary to manage deteriorating patients
To provide optimal and seamless care to surgical patients, surgeons ought to be equipped with the techniques of critical care. The acute critical care course (ACCC) is a major step towards bridging the gap that has resulted from undergraduate and postgraduate education, which has focused on imparting knowledge rather than developing practical skills (technical and non-technical) in providing safe, critical care to save lives. Sokhal et al. emphasized that a blended learning set of ACCC objectives form pillars for skill development.25 ‘Role play’ is more effective in training communication skills in ACCC than lecture-based teaching, as highlighted by Kumar et al.26 Kumar et al. demonstrated that training in communication skills forms a key component of ACCC that would improve patient care, relatives’ satisfaction and the image of the medical profession.26 An inference of Tables 4 and 6 is: ‘Simulation-based training in developing technical and non-technical skills is a key to safe and effective patient care’.25–36
Summary of review of literature
Introducing a simulation-based training programme is key to improving outcomes of deteriorating patients in India. There is an inherent resistance to change that has become endemic.1,3,16 The main challenge is having the ability to choose the most appropriate leadership strategies specific to each of these hurdles.
DISCUSSION
The findings of this analysis reaffirm that possessing competence in both technical and non-technical (human factors) skills is crucial for providing effective care to sick surgical patients. Simulation is not used consistently in surgical and medical training in India. The response to ACCC flyers has been variable and patchy. However, it is possible to overcome an ‘inherent resistance to change’ by making use of academic links, administrative connections, and diplomatic skills. The ACCC team has managed to identify a range of hurdles in establishing a new course in teaching hospitals in India by implementing various leadership approaches. Our findings demonstrate that the application of an interactive, simulation-based scientific approach is perceived as a welcome change, rather than dull and ineffective lectures.
Disinterest in implementing a critical care course
Unfortunately, most surgeons in India believe that the acquisition of operative skills (cutting, dissecting and suturing) is the most important attribute. The biggest obstacle in the Indian setting is the misconception that surgeons do not need training in critical care techniques, and therefore, ‘the postoperative care is someone else’s problem’. Surgical teams often seek expert opinions from relevant specialties for the management of apparently simple medical problems (such as respiratory, cardiac, or renal), which can result in delays. The ethos of ACCC is to enable each candidate to evolve into an effective clinical leader.
Lack of trained faculty who teach critical care using simulation
Most doctors have not had formal training in implementing educational theory and techniques. Most of us have watched popular teachers and imbibed some of their teaching styles. ‘Mimicry is the best form of flattery’, is the mechanism at the subconscious level that inspires good teachers to imbibe the teaching style of their teachers in medical colleges. A 1-day ACCC instructor course was developed to train high-quality ACCC teachers.
Changing the mindset in accepting a training course that is seen rather suspiciously as imposed by ‘foreigners’
Quite often, doubts have been raised: ‘Why doctors working in the UK or Australia are “trying to impose” this newer approach to training? What is their motive?’ Their concerns have been allayed by clarifying that ACCC is a totally indigenous course and has been continuously refined since its inception in 2014. Moreover, 80% of the pictures in the ACCC manual, case-based discussions, and teaching slides have emanated from the clinical work at Jan Swasthya Sahyog, a hospital in a remote tribal area of central India.24 It is crucial to find why there is resistance in teaching hospitals in India to adopting newer approaches to training. Bibby et al. emphasized the importance of self-awareness, self-confidence and self-control in regard to one’s strengths and limitations.37 The insight, or rather the lack of it, does have an impact on a clinician’s ability to manage a tricky clinical situation often encountered in the preoperative and postoperative phase of sick patients. In the ACCC provider and ACCC instructor courses, faculty members endeavour to modify the behaviour of medical professionals to optimize team dynamics. Lund et al. suggested the ‘reconstruction of behaviours’ using a range of educational strategies:38 (i) Intellectualization; (ii) sensing and scaffolding; (iii) accentuating the authority and respect of the trainer; and (iv) relation building.
To introduce a change, motivated leadership in each medical school and teaching hospital in India is of paramount importance who are self-sufficient in introducing simulation-based courses, such as ACCC, for the benefit of their own undergraduate and postgraduate trainees.
Limitations and strengths of this review
The study’s biggest strength is the large number of publications included in the analysis. There is a lack of quantitative interventional research publications, which limits the quality of the literature review. Due to considerable heterogeneity (in terms of methods, clinical parameters, study types, and analysis quality), it was not easy to tabulate and compare (or merge) the data from various studies. There were appreciable variations amongst the investigators regarding questionnaires and the mode of recording of feedback. There is considerable variation in the level of skills in using simulation for training, punctuality, and work culture across India. Quality control of ACCC courses to ensure nationwide uniformity would require standardized training of faculty members and a shared vision among all course directors across the nation.
Recommendations and future direction
Identifying barriers and challenges is crucial for implementing a new training programme.
For the successful implementation of a new training programme such as ACCC, it is crucial to have a highly motivated core group of leaders among medical professionals who possess a range of leadership styles.
Simulation, including role play, is a powerful training modality.
Conclusion
The focus of current surgical training in India is limited to acquiring high-quality operative skills rather than learning how to manage life-threatening conditions in the peri-operative period. A long list of barriers to the implementation of ACCC requires a range of leadership styles to manage the plethora of challenges. Low-fidelity simulation, using role-play, breaks the monotony of classroom teaching, encourages interactive learning, and facilitates active participation. A range of leadership skills (in an individual and collectively as ACCC faculty) is needed to deal with a plethora of situations for a successful implementation on a national scale. Sharing the vision document of ACCC with medical directors of teaching hospitals and with the deans of medical schools is a crucial step in disseminating this course on a pan-India basis.
ACKNOWLEDGEMENTS
We acknowledge the faculty, administrators, and deans of various medical colleges where ACCC was held, as well as the support staff who helped us organize this course more than 45 times in the past 8 years.
Conflicts of interest
None declared
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