Each simulation session consisted of four scenarios (Table 1) and was attended by four residents. Each scenario was led by one of the four residents, while the other three interns observed the scenario using real-time audio and visual feed. Immediately after each scenario, the scenario participant and the three observers were involved in a shared debriefing. All scenarios ran approximately 10–15 min and were designed as acute floor emergencies with the planned patient disposition to the ICU. In advanced cardiac life support (ACLS)-based scenarios (ventricular arrest, asystole, pulseless electrical activity arrest), one learner was designated the leader, while the others were active within the scenario as code members to add to the case fidelity. A nurse confederate was used to facilitate each simulated scenario, and scenarios concluded with appropriate consultation to the ICU. To increase realism and learner “buy-in,” care was taken to ensure that the background to each patient scenario or “stem” was applicable to the learner’s specialty. For example, the scenario of pulmonary embolism, led by an orthopedic intern, would involve a patient who was 3 weeks postoperative from external fixation of a fracture; if this scenario was led by a gynecology intern, it would involve a patient of posthysterectomy status. During scenarios focusing on communication skills (death notification and medical error disclosure), a standardized participant acted as a simulated family member. Finally, to create experiential fidelity in cerebral vascular accidents, a standardized patient was used to demonstrate acute hemiplegia and aphasia. For procedural skills, task trainers were incorporated within the context of the case as well as outside the direct scenario for additional deliberate practice.Table 1Overview of simulation sessionsSession #1 ACLS—ventricular tachycardia/therapeutic hypothermia Anaphylaxis/medication error disclosure Central line/ultrasound guided central line placement Surviving sepsis campaignSession #2 ACLS—asystole/death notification Symptomatic bradycardia-transcutaneous pacing Pulmonary embolism ACS/NSTEMISession #3 ACLS—unstable SVT/synchronized cardioversion Status epilepticus/lumbar puncture PEA/hyperkalemia/airway management (video laryngoscopy) Cerebral vascular accidents and thrombolytics