Date of Award

January 2011

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Leigh V. Evans

Subject Area(s)

Medicine, Educational technology, Curriculum development


Simulated Death: The Perceived Stress And Its Impact On Undergraduate Medical Education

Benjamin Zabar, Kelly L Dodge, Basmah Safdar, Sanziana Roman, John Sather, Christopher Moore, Brian Biroscak, & Leigh V Evans. Yale Department of Emergency Medicine, Yale University School Of Medicine, New Haven CT.

Objectives: To determine perceived stress of medical students during simulated patient death, the impact of assigned role, and the effects on learning.

Methods: This was a prospective, single blinded, randomized cross over study of third year medical students who participated in a 12 week simulation course using a high fidelity mannequin (Laerdal SimMan®) during a required surgical clerkship. All students completed a standardized multiple choice question examination (MCQE) with nine questions each on acute myocardial infarction (AMI) and pulmonary embolism (PE). Students were initially randomized to two groups: Group PE/AMI and Group AMI/PE. During weekly one hour simulation sessions, each group had five student participants and an assigned team leader in a clinical scenario, while another six students observed; the students switched roles for a second related scenario and were then debriefed. During the second scenario, the simulated patient suffered cardiac arrest. At week 6, all students were exposed to a cardiac arrest scenario for which the patient was successfully resuscitated, while at week 10 the simulated patient expired. After simulation sessions at weeks 6 and 10, the students were debriefed and rated their stress during the arrest scenario on a 0-10 semantic differential scale. All students took the same MCQE at week 12.

Results: We enrolled 163 medical students from 09/07-06/08, 79 in Group PE/AMI and 84 in Group AMI/PE. The mean pretest score for Group PE/AMI and Group AMI/PE were comparable for AMI (4.8 v 5.0; P = 0.30) and PE (4.2 v 4.2; P = 0.86). Students did not report significantly different stress for both successful resuscitation and patient death. (4.8 v 4.9; P=0.88) Team leaders reported the most stress followed by participants and then observers for both the successful resuscitation (6.7 v 5.5 v 3.9; P<0.01) and patient death (7.3 v 5.2 v 4.1; P<0.01). Score improvement out of nine possible points was similar between patient survival and death [AMI: 1.3 v 1.7 (P = 0.10); PE: 0.42 v 0.38 (P = 0.50)]. Post-test knowledge scores showed significant improvement for team leaders compared to non leaders for both AMI (2.6 v 1.3; 14% difference, P<0.01) and PE scenarios (1.4 v 0.23; 13% difference, P< 0.01).

Conclusions: Medical students did not find simulated death to be more stressful than successful resuscitation. The role of team leader was more stressful than participating or observing cardiac arrest scenarios. No evidence was found that simulated death impairs medical student learning, therefore it may be an appropriate scenario outcome. Assigned team leaders demonstrated the greatest improvement in knowledge.


This is an Open Access Thesis.

Open Access

This Article is Open Access