Author: Jordan Francke, MD, MPH
The Daily Dose
High-fidelity simulation provides a valuable method for evaluating how anesthesiologists respond to rare but life-threatening perioperative emergencies. At the 2026 IARS and SOCCA Annual Meeting, medical education experts presented findings from two major simulation studies examining clinical performance, decision-making, communication, and crisis management among anesthesiologists at different stages of their careers.
The Simulation Assessment Research Group is a national multidisciplinary consortium involving 12 institutions, the American Board of Anesthesiology, and private industry. Its research focuses primarily on using simulation to assess physician performance.
Performance gaps during perioperative emergencies
Matthew Weinger, MD, discussed the MOCA Sim study, which evaluated board-certified anesthesiologists during 20-minute simulations involving one of four perioperative emergencies.
Common performance deficiencies included failing to call for assistance, inadequate communication with the surgeon, insufficient escalation of treatment, failure to perform cardioversion or defibrillation for unstable arrhythmias, and failure to use emergency checklists.
These findings suggest that poor crisis performance may not result solely from inadequate medical knowledge. Communication, teamwork, treatment escalation, and the use of cognitive aids are also critical components of effective emergency management.
The IMPACTS study
William McIvor, MD, FASA, described the Improving Medical Performance During Acute Crises Through Simulation study, known as IMPACTS.
The study included junior, midcareer, and senior anesthesiologists and examined whether simulation performance was associated with American Board of Anesthesiology examination scores.
After completing each simulation, participants underwent a 40-minute cognitive interview. Their performances were evaluated by five independently trained and blinded video reviewers.
Senior anesthesiologists achieved the highest simulation scores, while junior anesthesiologists had the lowest scores. Previous simulation experience did not significantly affect performance.
There was also no meaningful difference between anesthesiologists practicing in community hospitals and those working in academic medical centers.
Simulation performance correlated strongly with scores on the ABA Standardized Oral Examination but did not correlate with written examination performance. This suggests that oral examinations and high-fidelity simulations may assess clinical judgment, communication, and real-time decision-making more effectively than written tests.
Understanding clinical decision-making
Michael H. Andreae, MD, PhD, discussed the difficulty of evaluating why clinicians make particular decisions during emergencies.
Researchers can easily observe actions, medication doses, and verbal orders. However, understanding a physician’s reasoning, expectations, priorities, and mental model requires additional investigation.
The IMPACTS researchers used cognitive task analysis by interviewing anesthesiologists immediately after each crisis scenario. The interviews asked participants to describe the clinical cues they noticed, the goals they established, the actions they performed, and the reasoning behind their decisions.
The study included 102 anesthesiologists across four locations and produced 408 interviews.
High-performing anesthesiologists anticipated crises earlier, developed more specific plans, and performed execution checks more frequently. However, both high- and low-performing physicians sometimes initially used temporary measures rather than immediately treating the underlying cause of the emergency.
Concerns about simulation performance
Laurence Torsher, MD, highlighted the concerning finding that approximately 25% of board-certified anesthesiologists performed poorly during the simulations.
He questioned whether these findings mean that anesthesiologists are inadequately prepared or whether current simulations sometimes emphasize emergencies that physicians may encounter rarely, if ever, during their careers.
Some deficient performances appeared to result from communication failures, delayed escalation of care, or failure to use available resources rather than from a lack of medical knowledge.
Simulation results should therefore be interpreted carefully. A physician who performs poorly during an unfamiliar simulation may still provide safe and effective routine clinical care. Nevertheless, rare emergencies require rapid and coordinated responses, making continued crisis preparation important.
The future of anesthesia education
The panel suggested that residency programs and continuing medical education should maintain a strong focus on common clinical situations that anesthesiologists encounter regularly.
Training should also emphasize communication, teamwork, calling for assistance, treatment escalation, and effective use of emergency checklists.
Artificial intelligence, decision-support systems, and other cognitive aids may eventually help anesthesiologists manage rare emergencies by providing rapid access to diagnostic and treatment guidance.
Clinical significance
High-fidelity simulation can identify important performance weaknesses that may not be detected through written examinations.
Experience appears to improve performance, with senior anesthesiologists outperforming junior physicians. However, board certification alone does not guarantee consistently effective management of rare perioperative emergencies.
The findings support combining medical knowledge with simulation training, communication practice, cognitive interviews, emergency manuals, checklists, and emerging artificial intelligence tools.
Preparing the next generation of independent anesthesiologists will require education that strengthens routine clinical practice while also providing reliable support for uncommon but potentially catastrophic events.
Thank you to The Daily Dose and IARS for allowing us to summarize this important discussion of simulation-based anesthesia education and crisis management.