So many roads: facilitated debriefing in healthcare.

The article by Rudolph and colleagues1 addresses a subject that is important to many involved in simulation in healthcare, but is not a traditional part of the training or experience of healthcare personnel. The topic is “facilitated debriefing,” but what exactly is this and why should we care? A little background may help explain. In the 1970s, several airliners piloted by highly skilled pilots crashed with no mechanical malfunction and under conditions not considered especially challenging.2 These accidents, plus NASA research that examined the performance of crews in full-mission flight simulation, led the airline industry and the US Air Force to realize that the technical skills of individual pilots are not sufficient by themselves to guarantee good outcomes. In the following years, the industry and NASA developed concepts that fundamentally changed the ways pilots are taught.3 “Crew resource management” (CRM) evolved as a set of principles that help pilots with crew communication and coordination, workload management, decision-making, and leadership. Pilots, both trainees and highly experienced “old hands,” now practice using these principles in challenging simulated flight scenarios. After the simulated flight, an instructor “facilitates” a “debriefing” in which the crew critically analyzes the events of the flight and their own performance.4 Facilitated debriefing required a substantial mind-shift by both instructors and trainees in aviation, and the same has been true in healthcare. Traditionally, training in most skill-based professions has been dominated by transfer of information from instructors to trainees. But research in several fields shows that individuals learn far better as active participants responsible for their own learning process, rather than as passive recipients of wisdom imparted from instructors.5 Furthermore, for trainees to become true experts and to continue their professional growth beyond formal training, they must also develop subtle metacognitive skills. Among these skills is the ability to critically analyze one’s own performance retrospectively—not just what went well and what went wrong, but why it went that way—which requires practitioners to critically re-examine how they mentally framed the situation confronting them. Individuals must also learn to critically assess how well they operated as a team. This assessment must go beyond rating performance; the team must be able to analyze how they interacted and how the interaction affected the outcome. Recognizing that the hidden part of the iceberg of errors in medicine is analogous to the situation in aviation, leaders in medicine have been adapting the concepts of CRM to team performance in healthcare, applying to both real-world activities and simulationbased training paradigms.6,7 Much of this work has borrowed extensively from the practices of CRM training including the use of facilitated debriefings as a key component of the exercises. In fact, practitioners of simulation-based CRM-oriented training in healthcare have described the debriefing session as the most important component of the simulation endeavor.