David Gaba, M.D.
Associate Dean for Immersive and Simulation-based Learning
Stanford University School of Medicine
Dr. Baile: Good morning, welcome to our Achieving Communication Excellence Lecture Series. And I'm Walter Baile, I'm director of the--our program on Interpersonal Communication and Relationship Enhancement. And today we're really pleased to have us our guest lecturer, Dr. David Gaba from Stanford University. Dr. Gaba is Professor of Anesthesia and Associate Dean for Immersive and Simulation-Based Learning at Stanford University School of Medicine. He also directs the Patient Safety Center of Inquiry at the VA Palo Alto Health Care System. Dr. Gaba was educated at North Western University where he received his undergraduate degree in Biomedical Engineering with a specialization in medical information processing. He went on to do his further medical training at Yale University and later his residency in Anesthesia--Anesthesiology at Stanford University where he’s been since 1983. David is a real pioneer in the field of simulation and edits the Journal of Healthcare Simulation. He's widely published in the area of patient safety, high-fidelity patient simulation and the effects of fatigue on healthcare personnel performance as well as team work and the simulation of training of healthcare personnel as they work in medical teams. Dr. Gaba receives funding for several grants from the government. And as I said, he's founder and founding editor-in-chief of the journal on Simulation in Healthcare. I think it's notable to mention that in the past several years, he has received several awards and recognition of these pioneering efforts in the simulation field. In 2010, he received the Kaiser Award for Innovative and Outstanding Contributions to Medical Education. And in 2011 received both the Society for Technology in Anesthesia, J.S. Gravenstein Award for Lifetime Achievement and the inaugural Department of Veterans Affairs and Undersecretary for Health Award for Excellence in Clinical Simulation Training Education and Research. So David spent part of yesterday and most of this morning really sharing his expertise with us and we’d like to thank him. And today he'll be sharing his expertise in talking about future vision of Simulation and Healthcare. Thanks Dave.
[ Applause ]
Dr. Gaba: Okay, got that technology sorted out. Well, you already know this part. I'm really very honored to be here. This is really an incredible place. And I'm very grateful that Dr. Baile and Dr. Botz invited me. And it's a pleasure to talk to you about this which is my life's work. So I have nothing to disclose for the ACCME but not related to the topic of this talk, you may want to know that I'm a consultant at [inaudible] incorporated about airway management stuff and on the scientific advisory board and a shareholder of SEA Medical Systems which is a start up that trying to make products to make IV delivery of drugs safer. It has nothing to do with this stuff.
So, one of the most important things to relate about simulation is that we consider it a technique, not a technology. As it says here, we use it for interactive and immersive activities to recreate what happens in the real world to make them better, to amplify them or to replace actual experiences that are too dangerous or too difficult to do for real. And borrowing from the band U2, I like to say that when it's done well, simulation can be even better than the real thing. And it's really not about technology, I think simulation has been done for a long time as a preparation for hunting or war so through the miracle of the Photoshop time machine here, you can see the guy on the left is doing a simulation training and then on the right, he's really happy that he had that training when he goes up against that thing, so. And I think people have been doing this for a long time. The applications of simulation are very, very broad and there are bunch of different ways to slice up the space of all the different possibilities. And I've written about 11 dimensions of cutting into that space to categorize it and I briefly want to go over most of these 11 dimensions.
So what is the purpose or goal of the simulation? We can use it for education and conceptual learning for early learners, for training which is teaching more experienced people the actual tasks, the actual work they’re going to do, for assessment, for research, many different purposes. We can do that with different units of participation, often with individuals, sometimes with teams, with whole work units or whole hospitals. Or around here, you can do the whole medical district then have umpteen hospitals and-- when people do disaster drills, that's an example of a whole hospital doing simulation at one time. We're going to use simulation to address many different levels of cognition, different--aspects of knowledge, skill, behavior or attitudes, the knowing, the doing, the deciding teamwork and many other issues. Different simulations address different aspects of this spectrum.
Simulations are applicable in many different clinical domains. I started with it in Anesthesiology about 26 years ago but it's applicable in the clinic, in the ward, in a place like cath labs, in the OR, the ICU, the ED, in psychiatry, in medicine, in peds, in surgery and other arenas. And for all disciplines of healthcare personnel, it's not just for doctors, not just for nurses. You can use simulation involving the ward clerks and the house keepers and allied health personnel and nurses and doctors and executives or boards of trustees or legislators. And across all the different experience levels of people, we do some activities for the K through 12 school population, for university students, most of what we do and most of what people do around the world is for professional school students for trainees and for experienced personnel. It's applicable to all ages of patients. There are simulations now for neonates and infants, for kids, for adults, for the elderly, haven't yet seen fetal surgery simulators, but probably only a matter of time till they're available. And as I say it's a technique not necessarily a technology but we often do use technologies and the spectrum of what we use for this technique runs from non technological things like role playing and verbal simulation to all the way up to virtual reality, computerized mannequins and so forth. I'll show some examples a little bit later.
Simulation can be accomplished with people sitting in their house or in the medical library, in a simulation center or in the actual work unit where they do their work what we call in-situ simulation. Youcan have different extent of direct participation. They can be viewing the simulation remotely. They can be viewing it remotely but have verbal interaction with the people who are in the simulation arena. There's been demonstrations of remote surgical simulation where the surgical simulator is in one place with the learner but the mentor is in another place. And of course, there can be direct on site interaction which is the most common way that we do simulation. Different methods of feedback that can be used, sometimes you don't need any feedback at all, just doing the simulation is the learning exercise. You can do the simulation, give the report to the instructor who sees what you did and gives advice. You can have an instructor in the room or you can use post talk debriefing with or without video and we'll talk about some of these similar as well.
So it's a very, very broad spectrum of what we can do with simulation. So just to go over the modalities of simulation again, there are the non-technological ones like verbal what if simulation sitting around, say what would you do if such and such happened. Role playing, story telling that we all do as clinicians sit around and talk about our tough cases is really essentially a form of simulation for the people listening, they're thinking, "Oh gee, what would I do in that situation?" There are computers screen simulators that represent the patient and the environment on the screen with photos, animations, movies and so forth. And that includes virtual patients which are like computerized actors if you will. There are part task and procedural trainers for learning the particular psychomotor tasks of healthcare. Shown down there is a laparoscopic surgery simulato. an endovascular cath-lab like simulator, and one of my favorites, the chicken simulator for central venous cannulation. One of the many techniques there are to teach the ultrasound and central venous techniques. And some of our faculty use the instrumented chickens which is kind of a--there's a large use of actors to play patients, they're known as standardized patient actors. Everybody in medical school has to do this now because it's part of the US Medical Licensing Exam. But increasingly, they're being used not just for medical students but for house staff training and CME training for experienced personnel and of course non physicians as well. There are online virtual worlds, sort of like world of war craft but for healthcare. This is a picture from one that's developed by some former Stanford faculty. Stanford faculty go out and form a company and do this kind of thing. And everybody has an avatar, they control in this virtual world, they can talk to each other, they can work on the patient, get information and so forth. And then there are the computerized mannequins, that's the field that I'm pioneering and that's heavily used for many different domains.
So, just a little bit of history, this was almost 26 years ago, this was couple of photographs of our pre-prototype simulation. And in those days we had--that was our mannequin head, no neck really or barely a neck. This was our audio visual system, a little tape recorder and this was most of the simulator control thing is with the biomedical engineers use to put way forms on monitors so they could test the monitors and stuff. Then this was sort of a next stage a year or so later, that's my medical student named Dian in the background who helped develop the first simulator. And we originally developed it as a research tool to understand problem solving by anesthesiologists in intraoperative problems. And so we did that with people of different levels of experience. This picture is of one of our senior faculty going through the same standard scenario that everybody had gone through and it contained a bunch of tough situations embedded in that scenario. A couple of years later, we had a further generation to that and seen at the top there is my colleague Steve Howard who's been on the faculty at the VA in Stanford with me for about 21 years or so, 20, 21 years, still with me there. And by 1991, we had a second generation simulator that had math models of the cardiovascular system and some other interesting things but all doing many of the same kinds of activities. So, one of the things we realized based on those studies of cognition and on our introspection of what it was like to work in an arena-like anesthesia or like intensive care, the ED or many other fields is that, yes everybody's got to have expert technical knowledge and skill, but that's not enough. That problemsstill occur that need to be handled with good decision making behaviors and optimal communication and teamwork behaviors or what are known as non-technical skills. And we didn't realize that completely ourselves, it turned out that in aviation, they've been seeing the same thing, they've been teaching stick-and-rudder skills to the pilots for many years, but planes were still crashing and it turned out that a lot of times it was because the crews didn't manage all the resources at their disposal to get the plane out of danger when that was technically possible. So in aviation, that resulted in a new kind of training called Crew Resource Management or CRM. And CRM is now pretty much the norm in commercial aviation both in this country and most of the world. And we weren't that much later than the airlines, maybe 5 or 6 years from the original early maturity of the CRM programs.
To realize that we have exactly the same kinds of issues in health care. This is a prototypical picture of a team managing a likely otherwise lethal anesthesia problem called malignant hyperthermia. And I don't think there's any question of who the leader is and whom the leader is talking to at this moment so it's a good prototype. And we realized that the CRM approach could be adapted to healthcare. We first published this adaptation in 1992, it was--the paper was rejected by the main anesthesia journal, so we ended up submitting it to a journal that knew something about the aviation business, Aviation, Space and Environmental Medicine. And I think now the anesthesia journal which has said that they'd publish the paper. We published the text book in 1994 and though it didn't come over in the transfer of the PowerPoint from Mac to PC, I do have to disclose, I got a dollar 33 in royalties for each one of those books that's sold. So I haven't quit my day job yet, but for those of you who write textbooks and stuff, it is really nice to get a check for something you did in the past. But--so that--that book sort of laid out the principles of Crisis Resource Management which was our adaptation in anesthesia. And about 10 years ago, we published a paper on our first decade of experience with this approach and now we have more than 2 decades of experience. We've been teaching this course for 21 and a half years now. So we have a fair amount of experience and it's gone from anesthesia only in those days to covering many, many different disciplines and domains of healthcare, not quite every discipline in domain but a whole lot of them. So it's time for another paper.
Now, in addition to our work, a lot people have been coming up with the variety of types of team work training in healthcare. A lot of them were seminar based in a conference room or in auditorium, sometimes with trigger videos to watch, sometimes with role play activities and so forth. But a few years ago, in the AHRQ WebM&M site, there was a point counter point about what is simulation, they had the team work training. Obviously, I was on the pro side of that and because I think that indeed simulation adds something especial to other forms of team work in communication training. And that is that it really engages the participants with both clinical and behavioral challenges. Here's a couple of my face validity pictures. So for example in the lower right, either that guy is totally engaged in the simulation or he's got a thyroid problem.
And I know it's not the thyroid problem and, you know, we have some Halter monitor data showing changes in both heart rate and heart rate variability with people in simulation that actually match the kinds of changes we see in real clinical settings, in the clinical settings particularly in neonatal resuscitation in the delivery room. But in these settings, they're not passive participants. They're really in to it. It can deploy in practice their teamwork skills, so it's not just about talking the talk but walking the walk.
And imagine that it might actually take practice to be able to do that rather than just the osmosis system we've always used, if you hang out long enough in clinical environments and you have some role models, you just pick it up as you go along, but people don't pick it up as well as they might. None of us is perfect and there's a lot of people who need more practice. In addition, you know, we don't do team work and nontechnical things in isolation, we do all that stuff while we're taking care of the patient. So those skills are executed in context during medical decision making in action, under these conditions that are listed here that make it very difficult. And if we only give people a chance to practice those things in a seminar room or in a real patient care setting, we're not getting the optimal situation in which people can really exercise and practice those skills.
Simulation allows us to do some things we really can't do in real patient care. We can let the nurses be doctors and the doctors be nurses. In my experience, I'd say it might be okay with real patients to let the nurses be doctors but we could never let the doctors nurses because doctors don't have a clue what nurses do either the tasks they actually execute or what its like to be in a nurse's shoes and have 5 people telling you contradictory things at the same time and--and in the simulation, we can let that happen and people can see what it is like to be in the other’s shoes. In addition, it's very useful for trainees who can learn what it's like to be it. And to be the one in charge the final decision maker with nobody who's supposedly able to bail them out. And in the old days, in our charity hospitals, our VA hospitals, we kind of let interns and residence do it all and whatever happened, happened. We don't do that anymore in all our patient care arenas, there's an attending who is legally responsible for the patient and really has to bail people out of trouble. But somehow people have to learn to be it for when they go out and they’re turned loose of an unsuspecting populace. And we can do that in simulation in ways we can't do real patients [clears throat], excuse me.
So there are now many flavors of team work training, what I've been describing is largely our approach at Crisis Resource Management but there's something called Team Steps which is very popular. The VA has a program called Medical Team Training. There are some commercial vendors often having an aviation background. So there are lots of different ways to get it some of the same issues and even those that didn't start using simulation are now including simulation in their programs for the most part.
Now, doing simulation is all about pedagogical choices. And for those of you who are involved, or may get involved in these kinds of things, the good news is--well, the bad news is there's no template of how to do these things. There's no turn key, you do exactly this and it will be great. Pretty much, you have so many choices you have to decide what's good for the particular population. You're going to deal with, with the particular goals you have, with the particular techniques that you think might be applicable and so forth. And all the choices are both a curse and a blessing. The blessing is it allows lots of creativity on your part. You have to decide, do I want to have a teacher in the room with people or do I want to leave the clinicians on their own? Like they would with, be with the real patient who'd--real patients don't have pause button? Do you want to do a debriefing after the simulation or not? Do you want to have people in their own roles or cross over the roles as I just talked about? Do you want to have actors and confederates in the simulations? And if so, how do you want to script them? Do you want to--if you're training anesthesiologist, you want to have a scripted surgeon who's friendly or not very friendly? You get to choose.
One thing to remember is that in making these choices, the goal is not necessarily to fool them. The goal is to teach them or do assess them or to do the research you want. And in fact, perfect reality isn't always desirable. We can use various kinds of unreality to maximize the learning or other goals for our target population. The instructor in the room is an example of what psychologists and education people call cognitive scaffolding. You build the scaffold to help the learner so they don't have to everything themselves, they can concentrate on learning a few things. You can give them cues and clues they wouldn't certainly have with real patients. Again, often for early learners that's a technique we may want to use. The simulator has a pause button. You can stop it, pause it, restart it, fast forward, rewind, restore it to a previous state if that's desirable. We can use time compression or expansion to get at the make things happen more quickly or less quickly than they would in real life to maximize the learning. We can use what we call death protection in the aviation business called crash protection. They can flip a switch on the simulator, you can fly down under the mountain, through the ground, back up into the air, you're not crashing the plane or they can set it so you crash the plane. We can do the same thing, we can--have a patient get sicker, sicker, sicker but never have a cardiac arrest because we don't want in a given day of simulation every scenario to be pumping on the chest and doing ACLS and stuff which could otherwise happen. So, we try and maximize the learning.
We have other choices. Do we do things for single discipline groups or for combined team groups? We'll talk about the pros and cons. We do them in a dedicated simulation center like you just have coming online here or we do things in-situ in the actual workplace, talk about that. Do you do especially in-situ stuff, do you do it as scheduled training or do you do it as unannounced mock events, we'll talk about that. So, single discipline courses, we say we're addressing issues for crews, from a single discipline and we're training the crews to work as teams. So when we do this approach like when we do our training for anesthesiologists, we will have confederates who play the other team members. The surgeon, the circulating nurse, one of the participants plays the scrub tech, we'll have other people to play it, OR technician or consultants like cardiologists, pulmonologists, blah, blah, blah. The advantage of this is it's logistically simpler to bring down a group from one discipline at a time. You can focus on the unique technical cognitive and teamwork issues for that particular discipline and you can expose participants to a wide variety of clinical situations and interpersonal situations. If you do a true combined team course, you'll get the surgeon and the nurse, you're going to get for that day along with the anesthesiologist and they might be really helpful, which is swell. But then the anesthesiologist has to learn to work with people who maybe aren't so friendly, or aren't so helpful on any given day. So when you do a single discipline course, you can set up the script to present the challenges to people that you want to present. However, it's not a real team. When you do a combined team course to train complete teams of staff who do work together or might work together in settings like the OR, the ICU, the ED, the delivery room, the cath lab, et cetera. You train actual teams to work as a team, you encourage cross discipline understanding in a way that's much more cogent than in a single discipline course, and you really give people this kind of multidisciplinary experience. This example is an ICU course with a physician and a nurse and there's a respiratory therapist in this case but there are also, there are physicians from different disciplines, there's a--other allied health respiratory therapist and so forth, all being trained simultaneously. And we think by the way that those techniques, single discipline and combined team, it's not one or the other. Ideally, it should be both because they're complimentary to each other. So what about the choice of in-situ in the workplace versus in a dedicated SimCenter? The pros of the in-situ thing are you probe and train people in the actual place where they actually do their work. You can unmask system issues and problems in those actual clinical arenas. They're pretty good for short courses and unannounced events and they're available to everybody, even for places that don't have a simulation center, everybody can do in-situ simulation. We've trained a 25-bed critical access hospital in a rural part of a rural state to do cogent simulations in-situ. There are cons to the in-situ approach and this picture is from one of our in-situs at the Stanford Adult Hospital, that's a rapid response team call for a massive upper GI bleeder.
These things are hard to organize, the schedule, the control and if you want to get video recordings of simulations, it's a lot easier in your dedicated SimCenter than out in the ward. The real clinical areas are often occupied or might be needed on a short notice, so to get an empty bay or bed to do an in-situ simulation is not always so easy. The simulations can be distracting to real care on that unit. The staff you have in the simulation are vulnerable to being pulled back to clinical duty whereas when you have them in the SimCenter you've kind of got them and short of a disaster, they really can't be pulled back. And in-situ, all the supplies we use are all the real supplies from that unit or from the code card or from whatever that people bring the--to the event and real clinical supplies are costly. The institutions have judged that that's a cost worth bearing for the systems probing and the learning that people get but depending on what you're going to do, you have to factor in those kinds of cost. So again these we consider as complementary techniques in the scheme of things that one or the other but probably both.
And the systems' probing is a really important part of this stuff. It's a key process improvement tool when you can provide known challenges for the system to deal with not just the people but the whole system. You get to define what the rules and parameters are of that evaluation. What is the case? What are you looking for? What are you trying to look at and sometimes it's just everything but sometimes you have very focused ideas of what you're trying to look at. We are pretty sure these scenarios, elicit behaviors that are likely to occur in real cases, maybe not exactly what the particular team would do in exactly that case tomorrow, but if they do it in simulation somebody is likely to do it in a real case. And it creates then the opportunities for change both for the individuals but more importantly for the health care system. So, I've presented a very rosy picture of what we can accomplish with simulation. What are the challenges that remain? Will there be pedagogical challenges? Just doing this kind of stuff well is tricky. Applying training with simulation comprehensively, nobody has really done it as much as we like to. Integrating the different modalities of simulation, so that you're really hitting all the things with the best way to hit them, nobody is really doing that yet and optimally integrating simulation training with all the other forms of training we use for trainees and experienced personnel, nobody has made that integration as well as we can yet. There are cultural challenges. If the real world doesn't reinforce the kinds of things we're trying to teach in simulation and it currently doesn't, it's not going to matter because design and culture training pretty much always, people spend a lot more time in the real world than they do in simulation and the incentives and the disincentives to their behaviors of various kinds really play out the real world and we can't reconstruct the motivational structure the real world in simulation fully. We can partially but not fully.
So we still have these challenges. And obviously, you can't read this slide which is part of the point here. I try to map out the funds flow for various things related to where money comes from and where it needs to go to and creating simulations and conducting simulations in different places and it's really complicated. You know, you've got philanthropy and clinical revenues and the GME money from medicare which may go entirely, and you've got places that it needs to go to and user fees and stuff you need to spend the money on for programs. And every place has a real problem with the money, one way or the other and it's really complicated. That is not going to go away and that is a continuing challenge to everyone. But it's not necessarily the rate limiting step. So, what do I think is the vision for simulation in health care going forward? First of all, it's a many decades long proposition, I used to think some of these things were a decade long proposition, I'm now in my third decade of doing simulation, I know this is going to take a long time. But we are shooting for a vision of training that is comprehensive and integrated, that's continuous over time for individuals, for teens, for work units that's coupled the performance assessment, so health care has been pretty lax about measuring and monitoring the performance abilities of our clinicians especially after we finish our training and we go out. You know, we're pretty much just out there, nobody's checking very much on whether we all still have it or not. And to do all this over an entire career, embedded in the process of what we do not as a, you know, separate add on. So we're shooting for a lifetime cumulative effect. A career long combination of modalities as I said these individuals teams, and otherwise, so people will repeatedly cycle through some didactics and seminars, on screen simulators or virtual worlds, the things and the dedicated center, things in-situ is unannounced or announced events and you just keep doing that. As I like to say, my vision is that for health care professionals, the only way you get out of doing this on a cyclical basis is if you retire from the business or you die, because if you're still taking care of patients, this is kind of what you need to do and this is exactly what's done in aviation and nuclear power and other industries of intrinsic hazard. You don't stop training just because you've been doing it for a few years already, it goes on forever.
So this is not a fad and just to illustrate this I want to illustrate the growth of simulation, the--in 2004, the membership of our society for simulation in healthcare, a 180 people, this year, 3500, so not quite 10 years quite a profound increase. Our attendance at the convention in 2003 is 128 people. The precursor meeting to these meetings was the Rochester simulation conferences. One of the social events for that was everybody went to Lindsay Henson's house for dinner. So this past January, we had 3100 people or more at our annual meeting, a little bit different than the old days. So this is not fad, it's here to stay. There are professional societies like the SSH as I say over 3500 members publishes the journal that I'm the editor-in-chief of does many other things, I'm also a part of this organization which is a 501C6 trade organization, meaning we could actually lobby the government, advocating for health care simulation in America. There are--there's a nursing association for clinical simulation and learning. There's an association of standardized patient educators. There are accreditation and endorsement programs by the SSH, by the American College of Surgeons for their things for the American Society of Anesthesiologists for our kind of simulation. This is all becoming part of the mainstream. It's the beginning, but it is becoming part of the mainstream.
What everybody wants to know where is the evidence, we live in the era of evidence-based medicine. This metaanalysis is about aviation derived team work training of all kinds concluded there isn't yet enough evidence to make a definitive conclusion. As you'll see, I think that's not surprising. I will tell you that incidentally, what's the evidence for simulation in commercial aviation and this is an industry where there's mandatory, yearly training and checking of flying performance in simulation, so you could graph studies on to those things that already exist. There's nothing like level 1A randomized controlled trial evidence in that arena and there never will be because it would be unethical to conduct such a study and the pilots are the first ones at the scene of the accident, so they really would prefer to have some special training of what to do when the engine fails. Now there have been a couple of recent reviews of the state of simulation research, one was an experts Utstein-style conference held in June of 2010, not at the--Utstein Abbey but in Copenhagen. This was published in our journal in June of last year. There are 20 experts from Europe and North America came up with bunch of key research topics.
Then just last year, the SSH held a research summit open to the public had about 400 attendees I think. There were 10 working groups that had white papers they created before the session and had break out groups in the 2-day or 1 and half day session and then updated those. And therefore, we had 11 monographs that appeared in the journal in August of 2011 as a special supplement that covers kind of the overview of the state of the evidence in a various aspects of simulation and various questions about simulation. Just to give you some of the highlights, everybody agreed that in almost all areas the evidence-based is small that the effective simulation on specific skills and tasks says the best evidenced-based though not perfect--I'll tell you a little bit more about this, that the design of simulator should leverage integrated system design. We don't do that yet …that we can use simulation as a research tool to understand patient care processes that we don't currently do, we do some of it in my lab has been one of the pioneers of that but we don't do enough of that. Concluded that simulation is indeed a powerful technique for performance assessment, that the metrics and psychometrics of simulation based assessment require more study but it is a unique window on performance and therefore can already be used even for high stakes exams if people have the will to do that. That's a whole seminar in itself-- the pros and cons of this. That another finding is we know that debriefing is a key pedagogical technique but we really have little evidence on what works best, when it works, how it works. There's a need for more theory base researched and study of the fundamentals. We need to study more variations around the so called standard approaches. I'll talk more about applying the translational research paradigm usually for clinical trials and so forth but to the simulation arena. And that, you know, simulation research needs to think about, we need to create more system--systematic programs of research not just one study at a time but bigger programs and things that really study in more detail, patient care processes and of course patient care outcome.
So as Bill McGahie at Northwestern who first introduced many of us in the simulation business to the notion of translational research paradigm applied to our field. The idea of translational research is you all probably well know is going from the bench to the bedside and there's some adaptation that's needed to adapt this concept to simulation but it kind of does work and there are different versions actually of the translational research paradigm even in clinical trial arenas and stuff that have been articulated but I'm going to tell you about my synthesis of a reasonable kind of nomenclature. So people applying this to simulation, we can talk about the T1 level which is measuring performance that occurs in simulation. So you taught them something, can they do it when you give them the simulation? T2 is performance during clinical care. You taught them something, when they go out in the wards, they really do it. The way you taught them with simulation, measuring that. A T3 level is seeing well, okay, if they do that, does it really change patient outcome? Is it efficacious and T3 prime is does it cost--does it save money, you know, is it cost effective to do that? The bean counters are really worried about that even when clinicians aren’t. Other people describe further levels of translational research because just because you show something works in one study, does it mean it can be disseminated that is can it be done by others? That needs to be studied. Willi people adapt it? You know, will they actually use it? And then if they do adapt it on a wide spread basis, will it work in one little study? Does it really change the outcome of populations as a whole to do these things? Well there has been very little research in simulation that goes beyond the T1 level. There is a little bit and not that much that's gone all the way up this ladder, virtually nothing that's no set of research that's gone all the up the ladder. So we have done up a fair amount at the T0 level of measuring, learning in the T1 level , it doesn't change their performance when you give them a simulation at least at the level of--in Miller's triangle of knows and knows how. There's modest proof of shows how at the T1 level. You know, can they do it when you give them the simulation but it's those studies are plagued by all sorts of methodologically difficulties. There are a few studies that do in fact, show improved clinical performance and even clinical outcome, T2, T3 studies but they are really hard to do. The poster child for this situation where the simulation intervention is circumscribed, where the outcome is easily measured and already being measured and the outcome is moderately common like infections and iatrogenic complications after central venous cannulation. We already measure that kind of stuff, we have surveillance for that and the interventions to teach people whether with the chickens or whatever is pretty circumscribed. So it's pretty easy to measure their performance and the patient outcome with some of these interventions in this kind of narrow window.
It's not so easy when you're talking about training people for events that are rare where the outcomes are subtle and hard to measure, where the behaviors and skills you're training are complex or the intervention is complex doing those simulations with, you know, crisis resource management and where there are many confounds between the intervention and the outcomes. So, not surprising there are T3 studies on a lot of these things, not surprising the meta analysis didn't show anything. So where we're at now in the simulation business is like, if we thought of simulation as a drug, would we go out and study a new drug by using a low dose of the drug, dosing it haphazardly to only a few people, not repeating the treatment whenever, you know, it might be necessary based on the characteristics of that drug, ignoring all the exacerbating factors using only a single treatment and certainly don't do that in this hospital, it's almost always combined forms of treatment, and following subjects for only a short time. It would be crazy to study a new drug this way. And especially crazy to then expect to see a big change in outcome but that's exactly what the state of evidence is in simulation. Most of our interventions have been infrequent, often with pretty low intensity curricula, with little reinforcement and real work, no coupling the performance assessment with only a few disciplines and domains in very small studies, only a few people in very short time horizons and, you know, for some things that may get you the evidence we need for a lot of things that's not going to cut it. And I think that the real test of simulation has a long time horizon, so a lot of the studies we do today, they're good studies but they chip away at small questions which is important work but they don't answer the big questions . The real question is does simulation improve quality when it's adapted long term in a comprehensive integrated way over a career as I said, coupling training and assessment and evaluated over a long time horizon. And we're talking maybe studies that would require 10 years or more than 10 years in dozens of clinical sites, hundreds or thousands of clinicians and thousands of patients and so far nobody is stepping up to the plate to fund those studies.
So, what are the drivers for moving forward in simulation? The professions as they say are really getting involved now incorporating simulation in into what the profession is expecting, both for trainees and experienced people. Sorry, some of the labels didn't show up in the transfer from Mac to PC but the liability ensurers are starting to get into the act and those are just someone's--some of those arena that I know about the healthcare payers not quite getting into the act but we hope to be starting to convince them that they need actually start making simulation part of their requirements for preparing people for the kind of work that they do that they pay them ultimately for doing. The regulators, accreditors and the government, in some small ways are starting to get in the act but many, many much bigger ways that they will be ultimately. Really ultimately, the public is the biggest driver and the ultimate driver and we don't really yet know how best to engage the public.
And, you know, does the public really care because historically, the public has shown they're more interested in access to care, cost of care than in quality of care, the politics of healthcare is quite complicated. Everybody wants to save money on everybody else's healthcare but not on their own. This is known as the corollary to Wildavsky's first law of medical money. And we don't yet know how to activate public support without scaring them. But it's something that to move forward, with or without evidence, with or without all the evidence we'd like that we're going to need to do to move this ball forward. So, I ask the question, why wait?
In 1992, I wrote this editorial about anesthesiology. It applies equally well to all of healthcare saying that no industry where human lives depend on the people doing the work really knowing what they're doing is weighted for unequivocal proof that simulation has benefits before they do it and healthcare shouldn't wait as it says at the bottom “waiting kills.” And people have been voting with their feet and adopting this for all the various pros that it offers, integrated of course with the rest of our apprenticeship training in healthcare, the rest of our modalities of assessment and process improvement. So the bottom line lesson is that this saying is so good, it occurs in different forms in both the Hebrew Talmud and in the Muslim Koran that whoever saves a life, it is as if it had saved all of mankind. So those of us who've been doing simulation and those of you here who are doing simulation already, I think can sleep better bit at night knowing there are lives, hearts, brains, and other organs that probably have already been saved by the work that's been done. The proof is hard to come by but we're pretty sure that it happens and if you save one life, it's as if you save all of mankind and that's a pretty nice think to think about. So, thanks very much.
[ Applause ]
>> Thank you David. I was just thinking musing over the fact that what we would really like when the patient says to us, "Do you mean I am being a guinea pig?" that we would just like to say, "No, because we've been to simulation school already." So, with that, I wanted to invite the folks to ask questions. So, let me just pose something that you mention that the non-profit that you have as a lobby for moving--for advocating simulation with various agencies. Have you had any impact for example on any of the boards that certified doctors in their specialties of even getting them to think about incorporating simulation into clinician assessment?
>> So where we are with the boards is for example in the United States, so in Israel the Anesthesia Board is already conducting part of the high-stakes board certification exam with simulation. In the US in anesthesia taking a simulation course is now a required part of the every 10-year maintenance of certification cycle. Examination with simulation is not yet required but there are a number of us in the field who are working on developing the evidence-base and the techniques to someday be able to do that, although, talking about simulation based board examination is a Kevlar vest kind of issue and I didn't wear my vest today, so but I think it will happen.
>> Thank you again so much for coming. We've really looked forward to this. It occurs to me that most simulation that's used for teaching and training and skill based in-situ that people are so busy using the facilities and planning how--planning the curricula that they're not thinking in parallel about the research. And so I think an awful lot of stimulation that's being done, its not including that component which would create the evidence and really drive the field. So I'm curious how you--some insight you might have about integrating the education, the pedagogy and the importance for the healthcare research.
>> So I'm standing next to a psychiatrist then I have to say I feel a little schizophrenic in answering this question because the half of me believes very strongly in the "just do it" philosophy, you know, like on the Nike commercials that we have enough reason to believe these things are useful, that it's more important to just get some things done even if you can't do the research that would be ideal to do. The journal editor half of me and tenured professor says, "Yes, we should build the research paradigms and to all the things we do so that we're not just doing them but also collecting data in building that evidence base." So yeah, I mean that's the ideal but everybody struggles with, you know, you can have paralysis by analysis. You can, you know, not do things because you're not ready to do the research. On the other hand, we need that research and I think the good news is that we have had kind of both in the field collectively. We have people doing things that seem to be useful and we have people doing research not for all the things but the research is being done. The big long horizon research can't be done because there's no funder for it. So I think that's a reasonable way to go.
>> Good afternoon Dr. Gaba. I'm so honored to meet you actually. I've been reading your literature for two years now. My passion is being in simulation and I can tell you here at Anderson we've been doing a type of dry run simulation in a BrainSuite. And I had the honor and please to mention how important the multidisciplinary team role has had over the 6 years actually that project has started. And my question to you is because I'm still working and hopefully as a conclusion on my PhD program a couple of years to bring to another research to the nation. What kept you over 10, 20 years actually to maintain that system ability of a practice and, you know, to validate what you've been doing because it's not easy. Although, I have a great support here, the anesthesia team and diagnostic imaging and nursing team has been of course the surgeons has been very supportive, so what was--what can you share?
>> Well, probably the most important lesson is to be persistent and, you know, start small and build up and just keep going even if people say you can't. Just, you know, I think in our case one of the beauties of being the first or one of the first is you have the whole field in front of you, so almost anything you do can be useful. And as the field has matured, it's gotten a little harder but I'm very gratified to hear about the progress that you sound like you're making. And, you know, we're in a different era now, we're--it used to be people said, "Oh, that's just a toy." And now they understand, I think reasonably well it's not just a toy. Their arguments now are not is it worth anything--isiat worth what we have to pay for it, to do these activities? And the simulators are cheap, it's the bricks and mortar that maybe expensive but the personnel or--you know, simulation is just a tool to do other things. Yet, a lot of institutions are voting with their feet as we say, believing that there are good reasons to keep doing these things so, you know, we worry that many times over the last 25 years that this whole field would die out and I think that worry is gone. This is not going to go away.
>> Well, I will keep going, thank you sir.
>> Any questions?
>> We're about to do a program here where it's going to be a communication project where there are some trainers who went through communication around--[inaudible] about caring and communication. And now, we'll have 9 months doing one scale a month in which on each team, these trainers will work with people and they'll be given scenarios and be told to give a tragic scenario of communication as versus a magic scenario of communication. And one of the things we observe, we have--it was easy for us to give the poor scenarios but it was difficult for us to give the magical scenarios a lot of times. And when we don't have that communication -specialist in the room with us now as we go back to our departments and we've just got someone who's agreed to be a trainer, how important is it to have like that really skilled communicator in the room or even if you may not have that person, just the process of doing it as a team and judging it as a team and offering feedback, do you see that as valuable?
>> Well, I think it is really useful to have an experienced debriefer who can come from many different backgrounds. And, you know, in our experience, we mostly use clinicians and clinical teachers as debriefers who we found can readily learn those skills some more than others and some put them in practice more than others. So even if you don't have one of the core communication expert facilitators, hopefully, you can get a cadre of the people in each of the clinical arenas who can do a credible job of that debriefing so that you have something that goes beyond just the experience itself. But it is always a challenge to extract the most you can out of any of these experiences.
>> Okay, thank you very much David for your--
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