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Simulation-based education has been shown to be an effective tool to mitigate skill decay. However, many of the strategies reported in the literature have overlapping terminology with little consensus on the timing of the strategy to prevent skill decay. In this review, we propose and provide a standardized nomenclature and framework for simulation strategies used to obtain, maintain, or regain skills that are decaying. This framework delineates four types of training: initial, maintenance, booster, and refresher. The framework differentiates these training types based on the learner competency at the time of the training, as well as the frequency and intensity of the training. Initial training is aimed at “novice” learners with the goal to achieve competency. Once competency is achieved, maintenance training prevents skill deterioration through low-dose high-frequency (LDHF) training. Booster training is used when the learner is still proficient, but competency begins to wane. Booster training occurs less frequently than maintenance training but with greater intensity to overcome the skill decay that occurs over time. Refresher training is aimed at re-establishing skill levels after competency has reached unsatisfactory levels. Refresher training is higher intensity than booster and maintenance training. We describe simulation-based strategies reported in the literature that can be used for each type of training. We conclude that there should be an increased emphasis in medical education towards maintenance and booster training in order to preserve skills before competency is lost. 

Acquiring and Maintaining Technical Skills Using Simulation: Initial, Maintenance, Booster, and Refresher Training