Portal de Periódicos da CAPES

Society for Simulation in Healthcare Presidential Address, January 2009

2009; Lippincott Williams & Wilkins; Volume: 4; Issue: 1 Linguagem: Inglês

10.1097/sih.0b013e318197d315

1559-713X

Michael A. DeVita,

Medical Education and Admissions

Welcome to the 9th Annual International Meeting for Simulation in Healthcare. I am pleased to be here and very honored to have been asked to serve as president of the Society for Simulation in Healthcare (SSH) in 2009. Those promoting simulation in the healthcare environment are a pretty diverse and rapidly growing group dedicated to the promotion and implementation of simulation in healthcare. (Figs. 1 and 2). Although the groups we represent may have competing priorities, we nevertheless have shared goals. I would like to discuss briefly the present state of healthcare simulation, a vision for the future, and our role in helping simulation reach its fullest potential in healthcare education, design, and safety.Figure 1.: Self-identified professional fields of Society for Simulation in Healthcare members. Source: Society for Simulation in Healthcare.Figure 2.: Growth of Society for simulation in Healthcare membership. Source: Society for Simulation in Healthcare.The SSH has left infancy and now has in place many of the structures of a mature professional organization. The SSH has developed or is developing (1) focused meetings among interested individuals, (2) an organized group that self-regulates, educates, and sets standards for the field, and (3) a journal and website that are widely accessible and focused sources of information. This year, under the guidance of David Gaba, Editor in Chief, our journal, Simulation in Healthcare, has been accepted for indexing by the National Library of Medicine in MEDLINE, an important measure of value. They deserve our heartfelt congratulations on achieving this milestone. The simulation field and the SSH are mature in the sense that it has achieved identity and created these structures to help lead growth and impact. WHERE ARE WE GOING? One of the questions we might ask ourselves is, “Where are we going?” Embedded in this question are a number of other questions that are related: Who are the people that should be included in the field? What are the needs of those involved in simulation to do it well? What are the needs of the healthcare educational system? How might simulation impact more fully healthcare design (architecture and processes)? What is the appropriate role of simulation in undergraduate and post graduate training programs? And perhaps most intriguingly, “What is simulation's full potential?” I think simulation outside of healthcare has reached wide acceptance even if it may not have been experienced by most people in this world. I look not only to the real world of aviation and warfare preparation upon which we have modeled many or our curricula but also to the imagined world of artists. In a sense, their progression is a path we might echo if not follow. In the 1970s “The Enforcer,” Clint Eastwood and a character played by David Soul engaged in a simulation exercise that has become iconic in film. Both navigate a wood-prop town and “criminals” or “friendlies” pop up, creating the opportunity to simulate killing innocents or bad guys. In the end, Clint “kills” a wooden cop. This sequence is an example of how relatively low tech and low fidelity simulation can be used for assessment, a goal which is now commonplace in healthcare simulation. Two subsequent films, “Police Academy” and “Men in Black,” parody this sequence and we see a panoply of errors in one and brilliant out of the box behavior in the other. Simulation has the ability to demonstrate the variety of ways errors can be made and how it can be used to test personality traits like problem solving behaviors. Both these objectives have real world healthcare analog: simulation techniques can identify latent system errors, and aid selection of medical school applicants.1 These practices will be refined and grow in scope and penetrance. Probably everyone remembers how Luke Skywalker learned to use a light saber, the simulation being high tech but low fidelity. It is a great demonstration of a partial task trainer and the need (or lack thereof) for high fidelity in training. It makes obvious how level of technology is not necessarily the same as fidelity and suggests the importance of selecting these qualities independently. A basic question for any educator is: “How can I best fulfill the goals of this exercise?” Movies are now progressing to more complex full-scale simulations. Take for example “Monsters Inc.” In the beginning of the film, one of the monsters sneaks up on a sleeping child, who suddenly awakens and is scared by the grotesque beast. Only after lights “go up” does the observer recognize the scene as a full scale, high tech, high-fidelity simulation. The same simulation used for demonstrative (lecture style) education, full-scale immersive education, as part of a sort of credentialing process, and finally as remediation. We do some of this now in the real world healthcare arena (especially as pertains to immersive and demonstrative education). Some organizations are using simulation techniques to remediate poor performers to “bring them up-to-speed.” I expect this practice to increase, although more data are needed to support its use in this manner. But my personal favorite simulation is in “Star Trek: the Wrath of Khan.” A young captain is commanding a starship manned by our favorite officers. A difficult tactical situation is encountered, and against advice, the captain goes against procedure to try a daring rescue. Many are killed. When they are surrounded by Klingon vessels, the captain tries to surrender only to find that Klingons, of course, take no prisoners. We later discover that this too is a simulation exercise. It is remarkable because it is a very high tech and ultra high fidelity simulation. I wonder if healthcare will ever need to be this realistic. It begs the questions we and all simulation workers must confront: “Is this type of simulation and degree of fidelity worth the cost? Does improving fidelity (and cost) add to the ability to achieve the goals of the exercise?” These are important questions that should be asked of any simulation application. As simulation leaders, it is our responsibility to show not only what can be done but also why it adds value. I am pleased to see that these questions are more commonly being addressed in manuscripts describing research in this realm, although more research is needed. The Star Trek simulation is remarkable also because no behavior by the trainee can lead to “success.” The exercise is designed so that the crew and the starship are always lost. The focus is not whether the trainee's choice, but rather how the trainee confronts highly stressful situations and deals with failure? The goal is to assess and promote the psychosocial “strength” of the trainee. In an ingenious twist, we learn that only Captain Kirk has succeeded in this simulation. He cheated of course by reprogramming the simulator, but this does nevertheless reveal a lot about his persona. The goal of the exercise—to assess and improve how the trainee deals with failure—was nevertheless achieved. Simulation exercises operating in the same domains exist, and focus on helping clinicians with end of life care, decision making, and professionalism.2 Computer simulations in film were used for epidemiology to demonstrate how a deadly plague will engulf the world unless the hero prevents it. Or help undo the plague: in “The 12 Monkeys,” experts use data to “rewind” a pandemic to identify the location of the trigger point, and then send a time traveler to prevent the outbreak. Error remediation at its finest! Desktop computer simulation for disease vectors in the Intensive Care Unit (ICU) mimics the movies,3 and holds potential for reducing labor intensive epidemiologic studies and perhaps may enable in computer simulated “controlled” studies. But as a safety officer, I think my favorite use of simulation is demonstrated in the film “Apollo 13.” A full-scale simulator designed for training astronauts' performance was used instead for equipment and process design. Confronted with scarce resources, and no procedures for a moribund spacecraft, National Aeronautics and Space Administration (NASA) created a plan for the astronauts to build a carbon dioxide scrubber from materials available. Then, to come up with the procedure to conserve energy and still power the spacecraft to earth, a multidisciplinary team, reconstructed the nearly dead ship in mission control to simulate the environment. They performed, reiterated, and revised in a simulated setting the process. They improved the result until it was successful in simulation. The simulation designed and tested process is sent to the astronauts, who used it and of course survived. But for the use of simulation, the ship and crew would have been lost. Best of all, the story is fact. Simulation can and perhaps should be a central methodology to process planning. So, where are we, and what can we learn from all this fiction and fact? We do not need to prove that simulation as used in the movies can work for healthcare. Rather, we need to imagine how it can be expanded to reach its full promise in healthcare design, education, and assessment. These movies I have mentioned show a vision of where we might go. During this meeting, we will all have the opportunity to see who is doing what, and how. We will see demonstrations of microsimulations, full-scale simulations, partial task training exercises, and standardized patients. We will also see new technologies: manniquins, trainers, computer based and virtual reality simulators. They will have been used for immersive education, remediation, assessment, and credentialing. Some will demonstrate how simulation can be used for healthcare design or forensic reconstruction of errant processes. We will learn from these sessions. We will want to own or copy these products. These projects are new and truly exciting, but in a sense are beside one of the major points I would like to make: we are currently operating in a healthcare environment that views simulation as supplementary or at best as an adjunct. Even at the most modern of simulation centers, simulation is a relatively minor adjunct. My question for you, and for the SSH is “What should the role of simulation be in healthcare?” To answer this, we must also ask, “What can we imagine it to become?” I want to explore in three realms healthcare education, safety, and healthcare design. EDUCATION Clinical healthcare education was revolutionized in the United States by Osler near the turn of the last century when he brought together the sickest patients, outstanding physicians, and trainees into a single academic hospital. This confluence of disease and faculty created not only a remarkable treatment arena but also an unsurpassed educational environment. The Flexner Report identified educational gaps, poor performance (and quackery), and lack of clinical experience in medical schools.4 He recommended the type of education Osler had created at Johns Hopkins. Their training model exists today in all the healthcare professions: preclinical lecture and book, followed by supervised clinical practice. It is a century later. Is this methodology the best way still? I asked a number of our simulation leaders to send me photos of their simulation center, or room, or technology (Figs. 3–5). All show great ingenuity and enterprise. They represent the leading edge of emphasis of simulation in education. And yet their programs are small relative to the total education trainees receive. What I mean is that they are for the most part outside of, or a small part of their healthcare educational system. Look at any medical school or a nursing school. Huge impressive buildings, with many lecture rooms of various sizes, more or less internet connected, a number of laboratories, and a library or two. Simulation labs, if they have any, are usually small in comparison to the rest of the physical plant. Simulation training hours are small relative to the whole educational experience (Fig. 6).Figure 3.: Danish Institute for Medical Simulation occupies the top floor of Herlev Hospital, Copenhagen, Denmark. Courtesy of Doris Ostergaard, Director, Danish Institute for Medical Simulation.Figure 4.: Center for Medical Simulation (CMS) is located on the first floor of this laboratory building in Cambridge, MA. CMS primarily serves hospitals in the Harvard Medical School system. With permission from D. Raemer.Figure 5.: MSR, Israel Center for Medical Simulation Virtual Hospital and Auditorium, is in essence an entire hospital, simulated. Reprinted with permission from MSR, Israel Center for Medical Simulation.Figure 6.: Relative emphasis on educational modality in healthcare education.Imagine the future: What is the best way to learn and to teach? Should and will these undergraduate organizations consider that simulation (immersive) techniques will be central to the educational process rather than being just a small adjunct to the learning “menu?” There is early evidence that the best way to learn, understand, behave, and retain, may be through simulation experiences. It is by doing that we learn best (at least that is the common sense if not evidence-based conclusion). Flexner and Osler moved education firmly into the clinic because that was the only way to accomplish experiential learning. Although our professors did the best they could with the technology they had available to them as they taught us, those tools may not be as effective and efficient as newer ones. We now have (or can develop) the technology to create a huge, organized library of simulation experiences. They may be simulated to be sure, but the mere fact that they can be organized and delivered at the instructor's convenience enables the healthcare educator to ensure that every trainee encounters and masters the clinical problem or skill. Consistent training to yield consistent results. This corrects a major problem with total reliance on clinical learning. In a sense, every one of us has had a different education, even if we went to the same school at the same time, with the same teachers. Our clinical experiences were highly variable. They shared only time frames and perhaps expectations. We saw different patients, diseases, and clinical dilemmas. Heterogeneous education results in heterogeneous quality. I would like us to embrace an educational system in which simulation is a core educational modality and not a minor supplement. Lectures can prepare for a simulation encounter (or may employ simulation techniques themselves). Journals and books can provide background or supplemental support for principles practiced in simulation. But simulation should be the core because it is measurable, focused, reproducible, mass producible, and importantly, very memorable. The change in educational improvement will be difficult and long. The onus will be on us to prove simulation works so well that it demands simulation's central role in education. It may be more ethical as well. Training clinical competence during simulation reduces patient risk. What is the role of simulation in the medical and nursing school? I think on the horizon is a revolution in educational methodology no less important than the changes Osler and Flexnor promoted over a century ago. Although it seems that much simulation education is now occurring, we do not know how much simulation is used in any educational setting. There are many outstanding centers, but there is no accurate count of how many simulation centers there are or where they are located. I am pleased to say that the Association of American Medical Colleges and SSH are engaging in such an inventory currently. It should be a model for other professions to use. An inventory is essential so we know where we are, to inform discussions of where we should focus effort, and to suggest how we need to grow as a field. SAFETY AND QUALITY The Institute of Medicine reports To Err is Human,5 and Crossing the Quality Chasm6 have shown us the clinical harm that occurs, and provides a roadmap for remediation. The desire to improve patient outcome has generated a new emphasis on safety and reducing variability is yielding profound changes in clinical care and safety. A cornerstone of some interventions is use of simulation education as it seems to produce error reduction in the clinic. The impact of simulation suggests a relative failure of other educational methods for clinical behavior that had previously not been well recognized. What is the measure of failed education in the preclinical educational environment? In part, it is low test scores. Remedial education can focus on improving the test scores but may have no impact on performance. The point is that the clinical education feedback loop and the basic knowledge feedback loop outside the clinical setting are not sensitive to failure. Put another way, measuring knowledge with testing may not be an accurate assessment of competence and ability to prevent errors. How should we measure a successful educational intervention? How prepared for clinical work can graduates be? We simply do not know the answer. But they are important questions. The answer may be fundamental to defining how we should prepare trainees to safely and competently care for patients. As we work to improve safety, we need to be cognizant of where our work fits into the education, safety, and cultural framework of our organization. I think as simulation leaders in our local environment, we need to integrate simulation methodology into core education for all healthcare professionals at all levels and in all fields. The picture of the nursing, medical, pharmacy, and respiratory care school should in the future conjure up an image of education fundamentally based on simulation methodology instead of an image of the blackboard, book, powerpoint, or teaching rounds. Those latter methodologies are not bad per se, but I think simulation has special potential for measurable impact on performance and safety. DESIGN There are two clinical design considerations that simulation can augment: equipment and process. I think many manufacturers are now using more and more simulation as they design of new devices, from the simple (defibrillators) to the highly complex (heart pumps). It is hoped that the practice will increase and lead to fewer latent design flaws. To date, simulation has not been reported often for process design, and yet it has huge potential. Take for example, the Toyota Production System (TPS) for process improvement originally created for making cars better. TPS requires observing practice and then making a series of small changes to improve consistency, efficiency, and quality. It has been successfully applied to healthcare, often by watching actual care delivery to patients. Although I approve of TPS, I can only wonder whether there may be a safer, more efficient, and more ethical method for improving process. Imagine doing any TPS project but using a simulated environment instead (as in “Apollo 13”). It is possible that the same results can be achieved more efficiently, and without having to catch failures as they happen in the course of patient care. Simulation TPS was a key to our process improvement and role delineation for resuscitation response, something we found very tough to address in the real world. Speaking of resuscitation response, the data are good that healthcare profession as a group need improvement at this interdisciplinary team process. Teamwork in healthcare is underdesigned and undereducated. It may be that the very medical, nursing, and allied healthcare provider schools we rely on contribute to the problem of poor teamwork. Evidence of the failure is the degree of unpreparedness that graduates demonstrate upon entering the clinical environment, especially in team efforts. To use a basketball analogy, it is as if we are training guards in guard school, forwards in forward school, and centers in center school, and then expecting them to compete well in the National Collegiate Athletic Association (NCAA) playoffs. Not a model for success. Simulation team training is moving out of its infancy and there are many examples of well designed teams (Figs. 7–9 show a few examples). It seems that these exercises have the potential to improve process for high frequency and rare events. We need to expand this use because all healthcare is a team activity.Figure 7.: Full scale, high-fidelity surgical simulation team exercise. Harvard University. This simulation is used to improve efficiency and reduce error. Performance and teamwork improve in this high-frequency high-risk clinical situation. Role delineation and process can be reinforced.Figure 8.: Extracorporeal membrane oxygenator (ECMO) team simulation exercise at Stanford University. ECMO is a low-frequency high-risk setting that can be error prone. Additional rehearsal can improve performance. Photo reprinted with permission of Lou Halamek, M.D., Center for Advanced Pediatric and Perinatal Education, Packard Children's Hospital at Stanford University.Figure 9.: Full-scale simulation team exercise for chemical gas exposure is an ultra low frequency, ultra high-risk event. It is hoped that a setting that health professionals will never encounter, simulation nevertheless enables the learners to develop skills, which will be lifesaving. Reprinted with permission from MSR, Israel Center for Medical Simulation.HOW THE SSH CAN LEAD The Society for Simulation in Healthcare had two important strategic meetings recently. The first was nicknamed a “visioning” session. In it we tried to imagine the place the simulation field should hold in healthcare education, assessment, and design, and which to some extent I have outlined. Although those results are still in process of being clarified and written, I can tell you that there was no consensus that simulation should be a core component in education, or design, and safety. Although data from Dirty Harry, Police Academy, Star Wars, and Apollo 13 support greater emphasis and time allocation, the reticence was appropriately based on the data currently available comparing the impact of simulation education versus other forms of education. Data are needed to clarify the potential for simulation and improve our practice. We need it to enable us to conjure what the future role of simulation can and should be. The second session built upon this and focused on the priorities for the SSH, and what resources are needed to achieve identified goals. These will be reported elsewhere, but in sum, the SSH has identified goals for the field, and strategies and tactics to foster those goals. I am very excited about the future of simulation. I am equally excited about our society and its ability to impact that future. It is my hope that the work we are doing today and tomorrow contribute as much to healthcare as the changes led by Osler which have come to define the healthcare environment in which we work and live. Although the movies are not real, they can stoke our imagination of what we might accomplish.