Simulation-Based Assessment Identifies Longitudinal Changes in Cognitive Skills in an Anesthesiology Residency Training Program.

OBJECTIVES: We describe observed improvements in nontechnical or "higher-order" deficiencies and cognitive performance skills in an anesthesia residency cohort for a 1-year time interval. Our main objectives were to evaluate higher-order, cognitive performance and to demonstrate that simulation can effectively serve as an assessment of cognitive skills and can help detect "higher-order" deficiencies, which are not as well identified through more traditional assessment tools. We hypothesized that simulation can identify longitudinal changes in cognitive skills and that cognitive performance deficiencies can then be remediated over time. METHODS: We used 50 scenarios evaluating 35 residents during 2 subsequent years, and 18 of those 35 residents were evaluated in both years (post graduate years 3 then 4) in the same or similar scenarios. Individual basic knowledge and cognitive performance during simulation-based scenarios were assessed using a 20- to 27-item scenario-specific checklist. Items were labeled as basic knowledge/technical (lower-order cognition) or advanced cognitive/nontechnical (higher-order cognition). Identical or similar scenarios were repeated annually by a subset of 18 residents during 2 successive academic years. For every scenario and item, we calculated group error scenario rate (frequency) and individual (resident) item success. Grouped individuals' success rates are calculated as mean (SD), and item success grade and group error rates are calculated and presented as proportions. For all analyses, α level is 0.05. RESULTS: Overall PGY4 residents' error rates were lower and success rates higher for the cognitive items compared with technical item performance in the operating room and resuscitation domains. In all 3 clinical domains, the cognitive error rate by PGY4 residents was fairly low (0.00-0.22) and the cognitive success rate by PGY4 residents was high (0.83-1.00) and significantly better compared with previous annual assessments (P < 0.05). Overall, there was an annual decrease in error rates for 2 years, primarily driven by decreases in cognitive errors. The most commonly observed cognitive error types remained anchoring, availability bias, premature closure, and confirmation bias. CONCLUSIONS: Simulation-based assessments can highlight cognitive performance areas of relative strength, weakness, and progress in a resident or resident cohort. We believe that they can therefore be used to inform curriculum development including activities that require higher-level cognitive processing.

[CHALLENGES IN LEARNING AND ASSESSING ANESTHESIA COGNITIVE AND NON-TECHNICAL SKILLS OF ANESTHESIOLOGISTS AND RESIDENTS IN ANESTHESIA].

INTRODUCTION: There are major challenges in teaching and assessing skills expected from practicing anesthesiologists and residents in anesthesia training programs. It is important to measure two separate aspects of skilled performance in managing crises: implementing appropriate technical actions (technical performance), manifesting appropriate crisis solving, and management of anesthesia non-technical behaviors. Anesthesia nontechnical skills (ANTS) can be divided into two subgroups: (1) cognitive or mental skills (decision-making, planning, strategy, risk assessment, situation awareness); and (2) social or interpersonal affective skills (teamwork, communication, leadership). Competency assessment of nontechnical (i.e. cognitive and affective) and technical (i.e. psychomotor) skills, is extremely hard to accomplish using only traditional examinations. The Accreditation Council for Graduate Medical Education (ACGME) has instituted an initiative that requires training programs to assess each resident's competence in several domains of medical practice. The ACGME toolbox for evaluation lists simulation training as the most effective evaluation strategy for medical procedures. Simulation scripts or scenarios can and should be aimed to evaluate and assess the technical and non-technical capabilities of residents in anesthesia. Lapsed or deficient non-technical (cognitive) skills, can easily lead to cognitive errors in anesthesia. Understanding and correcting cognitive errors cannot be overemphasized. Cognitive errors are thought-process errors which lead to incorrect diagnoses and/or treatments. To achieve error-free levels, learning objectives and curriculum/teaching should be adjusted to address the deficiencies identified in these learning skills. To reach this aim, educational training in cognitive errors, meta-cognition, and de-biasing strategies is needed. However, there are still many questions regarding which errors are most important to address and which "adjustment" learning strategies are the most appropriate and effective in anesthesiology. Sharing scenarios can provide an objective comparative view of trainees in different residencies, and the potential for universal applicability of such scenarios, and learning from the mistakes detected. Communication and collaboration among centers involved in simulation programs (including sharing of validated scenarios) is important to the future of this technology and approach. In summary, cognitive and non-cognitive simulation-based skills assessment that included the so-called ANTS can help to identify areas of strength and weakness that can be used to guide the residency curriculum, especially regarding deficiencies in tasks requiring higher order processing. Any such deficiencies need to be addressed in any training program.

A simple diagnostic test to confirm correct intravascular placement of peripheral catheters in order to avoid extravasation.

BACKGROUND: Intravenous catheters are ubiquitous among modern medical management of patients, yet misplaced or tissued cannulas can result in serious iatrogenic injury due to infiltration or extravasation of injectate. Prevention is difficult, and currently few reliable tests exist to confirm intravascular placement of catheters in awake spontaneously breathing patients. METHODS: Twenty conscious spontaneously breathing healthy volunteers were injected with 50 mL normal saline and 50 mL 4.2%, or 50 mL 2.1%, or 20 mL 4.2% sodium bicarbonate in a random order. A blinded anesthetist observed continuous sampling of exhaled carbon dioxide and was asked to differentiate between the sodium bicarbonate and saline injections. Peak increase in measured exhaled carbon dioxide was also calculated. RESULTS: Exhaled carbon dioxide increased significantly in participants injected with intravenous sodium bicarbonate. Mean peak increase was 7.4 mm Hg (±2.1 mm Hg) for 50 mL 4.2% sodium bicarbonate, 4.7 mm Hg (±2.5 mm Hg) for 20 mL 4.2% sodium bicarbonate, and 3.5 mm Hg (±1. 8 mm Hg) for 50 mL 2.1% sodium bicarbonate. The blinded observer correctly identified the injection as sodium bicarbonate or normal saline in every instance. DISCUSSION: Intravenous injection of dilute sodium bicarbonate with exhaled carbon dioxide monitoring reliably confirms correct intravascular placement of a catheter. A transient increase of exhaled carbon dioxide by 10% or more is an objective and reliable confirmation of intravascular location of the catheter. We recommend using 20 mL of 4.2% sodium bicarbonate to minimize the mEq dose of sodium bicarbonate required.

Simulation-based assessment to evaluate cognitive performance in an anesthesiology residency program.

BACKGROUND: Problem solving in a clinical context requires knowledge and experience, and most traditional examinations for learners do not capture skills that are required in some situations where there is uncertainty about the proper course of action. OBJECTIVE: We sought to evaluate anesthesiology residents for deficiencies in cognitive performance within and across 3 clinical domains (operating room, trauma, and cardiac resuscitation) using simulation-based assessment. METHODS: Individual basic knowledge and cognitive performance in each simulation-based scenario were assessed in 47 residents using a 15- to 29-item scenario-specific checklist. For every scenario and item we calculated group error scenario rate (frequency) and individual (resident) item success. For all analyses, alpha was designated as 0.05. RESULTS: Postgraduate year (PGY)-3 and PGY-4 residents' cognitive items error rates were higher and success rates lower compared to basic and technical performance in each domain tested (P < .05). In the trauma and resuscitation scenarios, the cognitive error rate by PGY-4 residents was fairly high (0.29-0.5) and their cognitive success rate was low (0.5-0.68). The most common cognitive errors were anchoring, availability bias, premature closure, and confirmation bias. CONCLUSIONS: Simulation-based assessment can differentiate between higher-order (cognitive) and lower-order (basic and technical) skills expected of relatively experienced (PGY-3 and PGY-4) anesthesiology residents. Simulation-based assessments can also highlight areas of relative strength and weakness in a resident group, and this information can be used to guide curricular modifications to address deficiencies in tasks requiring higher-order processing and cognition.

Inconsistency between simultaneous blood pressure measurements in the arm, forearm, and leg in anesthetized children.

STUDY OBJECTIVE: To determine the accuracy and precision of simultaneous noninvasive blood pressure (NIBP) measurement in the arm, forearm, and ankle in anesthetized children. DESIGN: Prospective, randomized study. SETTING: University medical center. PATIENTS: 101 ASA physical status 1 and 2 children (aged 1-8 yrs) scheduled for elective surgery with general anesthesia. MEASUREMENTS: Simultaneous NIBP measurements were recorded at the arm, forearm, and ankle at 5-minute intervals. MAIN RESULTS: The systolic blood pressure difference between the arm-forearm or the arm-ankle was within the ± 10% range in 63% and 29% of measurements, and within the ± 20% range in 85% and 67% of measurements, respectively. The diastolic blood pressure difference between the arm-forearm or the arm-ankle was within the ± 10% range in 42% and 44% and within the ± 20% range in 67% and 74% of measurements, respectively. In patients in whom the initial three NIBP measurements were within the ± 20% range between the forearm and arm, 86% of the subsequent measurements were also within that limit. CONCLUSIONS: Forearm and ankle NIBP measurements are unreliable and inconsistent with NIBP measured in the arm of anesthetized children. These alternative BP measurement sites are not reliable in accuracy (comparison with reference "gold" standard) and precision (reproducibility).

Construct Validity and Generalizability of Simulation-Based Objective Structured Clinical Examination Scenarios.

BACKGROUND: It is not known if construct-related validity (progression of scores with different levels of training) and generalizability of Objective Structured Clinical Examination (OSCE) scenarios previously used with non-US graduating anesthesiology residents translate to a US training program. OBJECTIVE: We assessed for progression of scores with training for a validated high-stakes simulation-based anesthesiology examination. METHODS: Fifty US anesthesiology residents in postgraduate years (PGYs) 2 to 4 were evaluated in operating room, trauma, and resuscitation scenarios developed for and used in a high-stakes Israeli Anesthesiology Board examination, requiring a score of 70% on the checklist for passing (including all critical items). RESULTS: The OSCE error rate was lower for PGY-4 than PGY-2 residents in each field, and for most scenarios within each field. The critical item error rate was significantly lower for PGY-4 than PGY-3 residents in operating room scenarios, and for PGY-4 than PGY-2 residents in resuscitation scenarios. The final pass rate was significantly higher for PGY-3 and PGY-4 than PGY-2 residents in operating room scenarios, and also was significantly higher for PGY-4 than PGY-2 residents overall. PGY-4 residents had a better error rate, total scenarios score, general evaluation score, critical items error rate, and final pass rate than PGY-2 residents. CONCLUSIONS: The comparable error rates, performance grades, and pass rates for US PGY-4 and non-US (Israeli) graduating (PGY-4 equivalent) residents, and the progression of scores among US residents with training level, demonstrate the construct-related validity and generalizability of these high-stakes OSCE scenarios.

Identifying and managing technical faults in the anesthesia machine: lessons learned from the Israeli Board of Anesthesiologists.

BACKGROUND: The potential for catastrophe resulting from anesthetic equipment failure and the failure of training programs to adequately prepare residents to detect and manage equipment failure prompted the Israel Board of Anesthesiologists to include simulation-based testing in the Objective Structured Clinical Evaluation component of the Israeli Board Examination in Anesthesiology. METHODS: We used simulation-based scenarios to measure the performance of residents while (a) checking the anesthesia machine before the first morning case, (b) checking the anesthesia machine between cases, (c) managing an oxygen pipeline failure, and (d) managing an expiratory valve failure. RESULTS: During board examination, 3 of 28 examinees failed to correctly check at least 70% of the items on the anesthesia machine checkout list before the first morning case and 3 of 30 failed to correctly check 70% of the items between cases. Although all examinees recognized inadequate oxygen cylinder pressure and a malfunctioning valve, 1 of 31 examinees failed to open the O(2) cylinder, 6 of 31 did not disconnect the anesthesia machine from the central oxygen supply, 14 of 31 could not explain how to minimize the use of oxygen, 2 of 30 failed to find the faulty valve, and 15 of 30 could not give the correct differential diagnosis. CONCLUSIONS: During simulation-based board examination most senior anesthesia residents became aware of equipment failures but many failed to correctly diagnosis and manage the failure.

Objective Structured Clinical Examination-based assessment of regional anesthesia skills: the Israeli National Board Examination in Anesthesiology experience.

Simulation techniques are increasingly being used in anesthesia training programs and to a lesser extent in evaluation of residents. We describe 7 years of experience with Objective Structured Clinical Examination-based regional anesthesia assessment in the Israeli National Board Examinations in Anesthesiology. We believe this is the first use of such mock scenarios for the assessment of regional anesthesia for the important purpose of national accreditation. During the study period, 308 candidates were examined in 1 of 8 different blocks. The total pass rate was 83%(257 of 308), ranging from 73% to 91%. The interrater correlation for total, critical, and global scores were 0.84, 0.88, and 0.75, respectively. Technological and cost constraints preclude actual assessment of regional anesthesia. However, testing formats that more closely reflect clinical practice are potentially valuable adjuncts to traditional examinations.

The diagnostic process and perioperative and anesthetic management of an undiagnosed congenital cyanotic cardiac defect in an adult for trauma surgery.

A 39-year-old patient awaiting emergency surgery due to a crush foot injury, with an undiagnosed cyanotic cardiac lesion that was diagnosed later as a complete atrioventricular canal defect, is presented. Complete atrioventricular canal defects usually present in the first few months of life and can be fatal if not treated in the first few years. Adult patients with congenital cardiac malformations seem to be at increased risk for noncardiac surgery. The diagnostic process, perioperative management, and anesthetic implications are discussed.

Treating myocardial stunning randomly, with either propofol or isoflurane following transient coronary occlusion and reperfusion in pigs.

Propofol and isoflurane may be used during fast track anesthesia for off-pump bypass, where transient ischemia is common. The purpose of this study was to compare the effects of propofol vs isoflurane in a porcine model of acute coronary occlusion. Twenty five pigs were randomized to receive general anesthesia with either isoflurane, 1 MAC (n = 13), or propofol, 3 mg/kg bolus followed by 200 microg/ kg/min infusion (n = 12). Pressure-tipped catheters were placed in the left ventricle (LV) and carotid artery; cardiac output was measured by ultrasound; two pairs of ultrasonic dimension catheters were placed in the subendocardium of LV. The slope of LV end-systolic pressure-volume relationship (Emax) was calculated. Reversible ischemia for 15 mins was accomplished with an occluder around the left anterior descending artery followed by reperfusion period. Measurements were done at baseline, end ischemia, early (5 min) and late (30 min) reperfusion. The data collected included systemic hemodynamics, LV end-diastolic pressure (LVEDP), dP/dt, Emax, and the presence of ventricular arrhythmias. The number of animals studied to completion was 19 (n = 11 in the isoflurane group; n = 8 in propofol group). There was a significant difference in Emax between isoflurane and propofol during early and late reperfusion [3.4 (0.5) and 4.0 (0.3) vs 2.6 (0.4) and 3.2 (0.5) mmHg/sec, respectively; P < 0.05]. Postreperfusion ventricular fibrillation occurred in 54% animals in the propofol group vs none in the isoflurane group ( P 0.05). Isoflurane administration was found to be cardioprotective against ventricular depression and arrhythmias compared to propofol.

Repair of concomitant valvular endocarditis using a single homograft.

Definitive treatment of complicated bacterial endocarditis requires surgical operation. However, the extent of bacterial endocarditis has dictated that surgical options be individualized. There are several surgical approaches to treat bacterial endocarditis. Transesophageal echocardiography has provided an invaluable intraoperative aid to the surgical decision-making and quality assurance of the repair. We report a case in which a primary aortic homograft was used for concomitant aortic and mitral valve repair based on transesophageal echocardiography evaluation. This case provides a new surgical alternative that uses a single homograft to repair aortic and mitral valves.

Supplemental oxygen compromises the use of pulse oximetry for detection of apnea and hypoventilation during sedation in simulated pediatric patients.

OBJECTIVE: The goal was to assess the time to recognition of apnea in a simulated pediatric sedation scenario, with and without supplemental oxygen. METHODS: A pediatric human patient simulator mannequin was used to simulate apnea in a 6-year-old patient who received sedation for resetting of a fractured leg. Thirty pediatricians participating in a credentialing course for sedation were randomly assigned to 2 groups. Those in group 1 (N = 15) used supplemental oxygen, and those in group 2 (N = 15) did not use supplemental oxygen. A third group (N = 10), consisting of anesthesiology residents (postgraduate years 2 and 3 equivalent), performed the scenario with oxygen supplementation, to ensure validity and reliability of the simulation. The time interval from simulated apnea to bag-mask ventilation was recorded. Oxygen saturation and Paco(2) values were recorded. All recorded variables and measurements were compared between the groups. RESULTS: The time interval for bag-mask ventilation to occur in group 1 (oxygen supplementation) was significantly longer than that in group 2 (without oxygen supplementation) (173 +/- 130 and 83 +/- 42 seconds, respectively). The time interval for bag-mask ventilation to occur was shorter in group 3 (anesthesiology residents) (24 +/- 6 seconds). Paco(2) reached a higher level in group 1 (75 +/- 26 mmHg), compared with groups 2 and 3 (48 +/- 10 and 42 +/- 3 mmHg, respectively). There was no significant difference between the groups in oxygen saturation values at the time of clinical detection of apnea (93 +/- 5%, 88 +/- 5%, and 94 +/- 7%, respectively). CONCLUSIONS: Hypoventilation and apnea are detected more quickly when patients undergoing sedation breathe only air. Supplemental oxygen not only does not prevent oxygen desaturation but also delays the recognition of apnea.

Treatment of ethanol-induced acute pulmonary hypertension and right ventricular dysfunction in pigs, by sildenafil analogue (UK343-664) or nitroglycerin.

In patients at risk for sudden ethanol (ETOH) intravascular absorption, prompt treatment of pulmonary hypertension (PHTN) will minimise the risk of cardiovascular decompensation. We investigated the haemodynamic effects of intravenous ETOH and the pulmonary vasodilatory effects of a sildenafil analogue (UK343-664) and nitroglycerin (NTG) during ETOH-induced PHTN in pigs. We studied pulmonary and systemic haemodynamics, and right ventricular rate or time derivate of pressure rise during ventricular contraction ( =dP/dT), as an index of contractility, in 23 pigs. ETOH was infused at a rate of 50 mg/kg/min, titrated to achieve a twofold increase in mean pulmonary arterial pressure (MPAP), and then discontinued. The animals were randomised to receive an infusion of 2 ml/kg ( n = 7) normal saline, a 500-microg/kg bolus of UK343-664 ( n = 8), or NTG 1 microg/kg ( n = 8); each was given over 60 seconds. Following ETOH infusion, dP/dT decreased central venous pressure (CVP), and MPAP increased significantly, resulting in significantly increased pulmonary vascular resistance (PVR). Within 2 minutes after treatment with either drug, CVP, heart rate (HR), and the systemic vascular resistance-to-pulmonary vascular resistance (SVR/PVR) ratio returned to baseline. However, at that time, only in the UK343-664 group, MPAP and dP/dT partially recovered and were different from the respective values at PHTN stage. NTG and UK343-664 decreased PVR within 2 minutes, from 1241+/-579 and 1224+/-494 dyne . cm/sec 5 , which were threefold-to-fourfold increased baseline values, to 672+/-308 and 538+/-203 dyne . cm/sec 5 respectively. However, only in the UK343-664 group, changes from baseline PVR values after treatment were significant compared to the maximal change during target PHTN. Neither drug caused a significant change in SVR. In this model of ETOH-induced PHTN, both UK343-664 and NTG were effective pulmonary vasodilators with a high degree of selectivity. However, the changes from baseline values of PVR, and the partial recovery of systemic pressure and RV contractility compared to the maximal change during target PHTN, were significant only in the sildenafil analogue group.

Coronary vasospasm during anesthesia induction: awareness, recognition, possible mechanisms, anesthetic factors, and treatment.

We describe a patient who developed severe ST-segment elevation, pulseless ventricular tachycardia, and cardiac arrest during induction of general anesthesia. This transient ST-segment elevation may have been the result of coronary artery spasm. Awareness of this variant of coronary artery vasospasm--Prinzmetal angina--in patients without clear symptoms or established ischemic heart disease, is the key to successful outcome. Recommended preparations and treatments are preoperative calcium channel blockers, nitroglycerin available intraoperatively, reduction of endogenous or exogenous catecholamines, and vigilant monitoring.

Blue dyes, blue people: the systemic effects of blue dyes when administered via different routes.

We report 4 patients who had facial color changes to a blue-green-gray color and decreased oxygen saturation as measured by pulse oximetry. Patient 1 received an intravenous (IV) methylene blue solution during a urologic procedure, and the remaining three patients were administered subcutaneous indigo carmine (patient 2) or Patent Blue (Patients 3 and 4) for axillary lymph node mapping. All patients had above normal methemoglobin levels. Two (Patients 2 and 3) had hypotension, and one (Patient 3) required IV ephedrine to restore hemodynamic stability. Patient 4 had a hypersensitivity reaction characterized by systemic urticaria and blue-colored subintegumentary edema due to the subcutaneous administration.

Credentialing and certifying with simulation.

Assessment and evaluation are integral parts of any educational and training process, and students at all levels of training respond by studying more seriously for the parts of the course or training that are assessed. To promote and enhance effective learning successfully, simulation and other teaching methods should be both formative and summative, because the ultimate goal is to ensure professional competence. This article describes a model of medical competence, and focuses on the use of medical simulation in assessment and evaluation of different levels of clinical competence using examples from experience.

Treating ischemic left ventricular dysfunction with hypertonic saline administered after coronary occlusion in pigs.

OBJECTIVE(S): The effects of hypertonic saline on ventricular function are controversial, whether it is increasing contractility or preload. There are no data, however, on the influence of hypertonic saline in a stunned myocardium. DESIGN: This study was prospective and randomized in order to analyze the effects of hypertonic saline solution (7.5%) on myocardial function and systemic hemodynamics in a porcine model of ischemia and reperfusion. SETTING: A university teaching hospital, animal research laboratory. PARTICIPANTS: Twelve adult domestic swine. INTERVENTIONS: Myocardial stunning was produced by the complete occlusion of the proximal left anterior descending artery for 15 minutes followed by reperfusion. Five minutes after reperfusion, the animals were assigned to receive 4 mL/kg of hypertonic saline (n = 7) or normal saline (n = 5) over 10 minutes. Pressure-tipped catheters were placed in the left ventricular cavity and aorta. The dimensions of the left ventricle were measured with ultrasonic microcrystals. Cardiac output was measured with transit time ultrasound. Data were recorded continuously and compared before the occlusion, 5 minutes after reperfusion, and at the end of the infusion. MEASUREMENTS AND MAIN RESULTS: Compared with baseline, ventricular function was significantly depressed after left anterior descending artery occlusion. Left ventricular dP/dT and its end-systolic pressure-volume slope decreased (38% and 52%, respectively; p < 0.05), with a concomitant increase in systemic vascular resistance. The administration of hypertonic saline significantly improved left ventricular function (Emax 1,422 +/- 198 mmHg/mL, and dP/dT 3.2 +/- 0.4 mmHg/s v normal saline group values of 1,156 +/- 172 and 2.5 +/- 0.5, respectively; p < 0.05), cardiac output (2.5 +/- 0.5 v 1.84 +/- 0.4 L/min, p < 0.05), and lowered systemic vascular resistance (from 28.8 +/- 2.3 to 23.5 +/- 1.4, p < 0.05), with no significant changes with normal saline administration. CONCLUSIONS: After transient myocardial ischemia, hypertonic saline administered over a short period of time acts as an inodilator by increasing contractility while simultaneously lowering systemic vascular resistance.

Treating metabolic impairment and myocardial stunning with phosphodiesterase inhibitor type III, milrinone, administered prior to coronary artery occlusion in the presence of calcium channel blockade in pigs.

This study examined milrinone effects on ischaemic myocardial metabolism and function with calcium blockade. We studied 15 pigs in 3 groups: group C received no drugs; group D received diltiazem 5 mg bolus followed by infusion; group D+M received diltiazem and milrinone (50microg/Kg). The left anterior descending (LAD) artery was then occluded for 15 minutes. Left ventricular (LV) function data obtained included rate, pressures, output, Emax, and dP/dT. Blood lactate was obtained from the LAD and circumflex vessels at baseline, end of occlusion, early (15 min) and late (1 hour) reperfusion. In group D+M, less depression of LV function occurred during ischaemia and early reperfusion. Lactate extraction in the LAD region was less negative in D+M group than in the group without milrinone during ischaemia and late reperfusion. We conclude the preemptive administration of milrinone prior to ischaemia added to calcium blockade improved myocardialfunction and ischaemic metabolic effects.

The validation process of incorporating simulation-based accreditation into the anesthesiology Israeli national board exams.

BACKGROUND: The Israeli Board of Anesthesiology Examination Committee added a simulation-based Objective Structured Clinical Evaluation component to the board examination process. This addition was made in order to evaluate medical competence and considers certain domains that contribute to professionalism. This unique and new process needed to be validated. OBJECTIVES: To validate and evaluate the reliability and realism of incorporating simulation-based OSCE into the Israeli Board Examination in Anesthesia. METHODS: Validation was performed before the exam regarding Content Validity using the modified Delphi technique by members of the Task Force of the Israeli Board Examination Committee in Anesthesiology. RESULTS: The examination has been administered six times in the past 3 years to a total of 145 examinees. The pass rate ranged from 62% (trauma) to 91% (regional anesthesia). The mean inter-rater correlations for the total score (all items), for the Critical checklist items score, and for the Global (General) rating were 0.89, 0.86 and 0.76, respectively. The inter-correlations between the five OSCE stations scores were significant (P< 0.01) only between Trauma & Ventilation for the Total score (r = 0.32, n=63), and between Resuscitation & Regional and OR-crisis for the Global score (r = 0.42 and 0.27, n=64 and 104, respectively). The correlation between the OSCE examination score and the success rate at each of the eight different clinical domains of the oral board examination did not reach statistical significance. Most participants (70-90%) found the difficulty level of the examination stations reasonable to very easy. All major errors, which were identified in the initial two exam periods, disappeared later in the next two exam periods. CONCLUSIONS: The exam has gradually progressed from being an optional part of the oral board examination to a prerequisite component of this test. Other anesthesiology programs or medical professions can adopt the model described here.