David Gaba, M.D.
Associate Dean for Immersive and Simulation-based Learning
Stanford University School of Medicine
Dr. Walter Baile: Hi. I'm Dr. Walter Baile, director of the MD Anderson Program on Interpersonal Communication And Relationship Enhancement or I-CARE. We're pleased to welcome today for our icare roundtable discussion Dr. David Gaba. Dr. Gaba is Professor of Anesthesia and Associate Ddean 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 received his undergraduate degree at Northwestern University in biomedical engineering with a specialization in medical information processing. He went on to do his medical training at Yale University and later his residency in anesthesiology at Stanford University, where he's been on the medical staff since 1983. Dr. Gaba's widely published in the areas of patient safety, hi-fidelity patient simulation, the effects of fatigue on health care personnel performance and teamwork, and simulation of training of health care personnel. He receives government funding for several research and educational projects in these areas. Dr. Gaba is founding editor-in-chief of the "Journal of Simulation in Health Care". As evidence of his accomplishments in 2010, Dr. Gaba received the Kaiser Award for innovative and outstanding contributions to medical education. And in 2011, he received both the Society for Technology in Anesthesia, J.S. Gravenstein Award for lifetime achievement, and the Inaugural Department of Veterans Affairs and the Undersecretary's Award for Excellence in clinical simulation training education and research. Thanks for being with us here today, Dave.
Dr. David Gaba: Oh, my pleasure.
Dr. Walter Baile: So I notice that you're originally trained in anesthesia but you got involved with now running a big simulation project and program and editing a journal. How did you make that transition?
Dr. David Gaba: Well, actually, I think it was natural that anesthesiology was the first medical discipline that really embraced simulation. We find we have a lot parallels between anesthesia and arenas like the airplane cockpit or the control room of a nuclear power plant. We have a very similar cognitive profile historically termed hours of boredom and moments of terror. In addition, anesthesia's a pretty technical field that it tended to attract people like me with an engineering background, and those things were married up together to having anesthesia as the arena that adopted mannequin-based simulation, other forms of simulation, and ran with that ball. So I just sort of started in that vein. We originally created the simulator, actually, to have a mechanism for conducting research on the cognition of anesthesiologists as they would solve tough intraoperative problems, and, of course, we knew it would have training implications as well.
Dr. Walter Baile: Could you tell us a little bit about some of the kinds of simulation that you're doing at Stanford with, in the simulation laboratory?
Dr. David Gaba: So we try and cover nearly all of the modalities of simulation. We consider simulation a technique, not a technology. So there are many forms of simulation that don't use any technology at all. There's verbal simulation. Sitting around and saying, well, what would you do if x, y, and z happened. There's role playing. We even consider storytelling as a form of simulation and note that, you know, people are moved to tears by reading books or watching movies, even though those are just ink on a page or lights on a screen. We also, for some of our technical procedures, will use food as simulators. So there's no better simulation of some of the organs in the body than [clearing throat] organs you can buy at the grocery store from animals. There must be millions of people who've learned to give an injection into an orange as well. And then we move into the kinds of things that go beyond that. We use actors quite a bit for simulations in the clinic setting where all you're going to do is interview the patient and possibly do elements of a physical examination. There's no better simulator than another human being. Unfortunately, the actors don't like to have needles stuck into them or tubes or have lethal diseases we may not be able to resuscitate them from. So in a lot of the more invasive and dynamic arenas of health care, we really have to have a technological simulator. In many cases, that's a computerized mannequin, which is the field that I've been a pioneer in, but there are also techniques of virtual reality, online virtual worlds where multiple players can interact together in the same virtual states with a virtual patient, and, of course, for learning procedures, there are a whole host of technological simulators of the parts of a task. Some of these simulators are very simple plastic models ranging all the way up to more virtual reality recreations of entire surgical operations such as in laparoscopic surgery or endovascular simulation for [inaudible] types of procedures. So we really try and cover to some degree or another the whole spectrum of those modalities.
Dr. Walter Baile: It's very interesting, and lately, maybe not lately because I think that with mannequins and some of the high-tech simulations, the ultimate goal is, of course, patient safety and proper technique as you mentioned. I noticed also that you've become very interested also in teamwork and in hand offs, which is a somewhat different set of skills, and how does it happen that you have developed modality for training people in that area? What exactly happens when you want to teach hand offs, and give us an example of what one might see if they were to watch a simulation of that sort?
Dr. David Gaba: One of the important historical antecedents was about the time we were developing the studies of cognition of anesthesiologists, we looked for models of decision making in other industries, and as I say, we looked a lot at aviation. At about that time in the mid 1980's, aviation was starting to mature an approach that went beyond the stick-and-rudder skills of flying to address the non-technical skills of flying, teamwork and communication and leadership and followership. And as we found out about that, this resonated quite a bit with what we knew introspectively was happening in health care. That those kinds of issues in our business, just like in aviation, were often the rate-limiting step, not that people didn't know technically what to do. So actually in the early 90's, we explicitly started to adopt and adapt the crew resource management paradigm that had been developed in aviation to apply to health care and addressing many of those non-technical skills that I've just mentioned. So in, oh, let's say, in operating room setting, which is my own arena, although these techniques have now spread to many other medical disciplines and domains, we will actually for let's say training anesthesiologists, we have a complete recreation of an operating room. We have anactual anesthesia machine. We have an OR table, but instead of the patient on the table, it's a computerized mannequin. There are people playing the role of the surgeon, the circulating nurse. In our case, one of the participants plays the role of the scrub techs, and they get to see the scenario unfold from the surgical side of the drapes, and then the anesthesiologist in the hot seat comes in and takes over a case from a colleague, and we can either have that be an urgent take over or routine take over, and then we can make all sorts of nasty things happen. If they call for help, they get one of their colleagues, who's been sitting in our so-called soundproof booth. So they come in not knowing what's been going on, which is exactly what happens when you run in to help a colleague, you go in cold. So that environment really recreates the characteristics and the stresses of natural environments. When things are happening dynamically, you have to work together as a team. Conflict can arise. You have to resolve the conflict. You have to communicate as explicitly as possible. Close the loop on communication and really organize both the environment and the team to achieve the best outcome for the patient.
Dr. Walter Baile: I know you've also been very interested in other aspects of patient safety, including practitioner fatigue, and I wonder if you could tell us a little bit about how you got involved with that, and what you've been interested in.
Dr. David Gaba: Well, that's another one that really, of course, we intrinsically knew as interns and residents. We were all fatigued, but, again, in studying aviation, they have work hours regulations, very tightly in aviation both on a monthly and a daily basis. In the early 90's, we organized an experts workshop on patient safety in anesthesia, and one of the experts we invited to that workshop was Bill DaMint, who was one of the fathers of sleep medicine. A Stanford emeritus professor now. And, you know, working with Bill galvanized some of my associates, in particular Steve Howard, one of my faculty colleagues who made the study of fatigue medical personnel his main area of research. And actually the simulator gave us a useful tool to do some of that work because we could actually study people's clinical performance when they were in their baseline state or very well rested or coming off of an actual or a pseudo call night where they'd been awake for a known period of time. We wouldn't be able to do that real patient care because a., it wouldn't be fair to keep people up all night and then have them continue to do more patient care, and b., we couldn't control what would actually happen to a real patient, but in the simulator, we could control what would happen. So we did some pretty interesting studies both in the standard sleep lab setting and using simulation.
Dr. Walter Baile: Now, I read somewhere that you can actually obtain a sort of a bio equivalent relating the level of sleep deprivation on how many hours you haven't slept, even blood alcohol levels, and so things are becoming pretty sophisticated in terms of looking at the impairment caused by sleep deprivation, and, of course, it's a very big issue now with our trainees and making sure that they don't get exposed to patient care when they've been, you know, up for three or four days.
Dr. David Gaba: Yes. I mean, those studies about the equivalent to blood alcohol level were done for psycho-motor skills of surgeons, but we think actually the issue is much broader than that. You know, there, it's well established that the first thing to go when you're fatigued is mood. Mood and the way you interact with other people. We all know that people when they're tired tend to snap at others and so forth. It's interesting. The simulation study showed that the performance decrement from fatigue for broader cognitive skills and these non-technical things is not so simple. It's not as easy to measure as some of the psycho-motor things. And, in general, people's performance wasn't that bad even when they were very fatigued as long as they were awake. At least in their cognitive abilities to detect and solve problems, but the problem is people tend to cycle in from being awake to being asleep, and we've all seen people nod off -
Dr. Walter Baile: Yeah -
Dr. David Gaba: And in some of our studies, we saw some individuals were asleep for 30 or 40 percent of a long boring case, but they'd be asleep and awake and asleep and awake. Well, obviously, when they're asleep, their performance is zero. When they're awake, maybe it's only a 20 percent decrement, but when they're asleep it goes to nothing. So it's a really interesting area, and actually I think we started to deal with this issue in our trainees, but, currently, we haven't dealt with it at all with the experienced personnel, whether doctors or nurses -
Dr. Walter Baile: And I would imagine that if you're sleep deprived, and as you mentioned more irritable and snappy, that the impact on working with a team would be another aspect of that, which is one could take a look at in a simulation setting, too.
Dr. David Gaba: Indeed, and also in working with patients and families -
Dr. Walter Baile: Right.
Dr. David Gaba: So there are many things still to look at in that whole arena even as slowly we start to deal with it -
Dr. Walter Baile: Yeah -
Dr. David Gaba: But we're really quite far from the societal norm for how health care deals with this issue versus the other industries of intrinsic hazard.
Dr. Walter Baile: Now, I had a chance to take a look at the journal, the journal of which you're editor, Simulation in Healthcare, and I was really impressed at the wide spectrum of diversity of the articles that were published there. From how to work with actors to how to intubate folks to, you know, how you follow up on people's performance, and it is an incredibly broad field that you're kind of looking down over as you sort of read the submissions to the journal. And I know that recently that you had published a paper kind of talking a little bit about, well, how to organize our priorities for research in education and the field, that using, I think you called it space science methods. And I wonder whether you could say something about that because it seems to me that there really are so many questions that how to prioritize them and sort of find some direction to identifying the most pressing issues is really important, and I kind of got a glint to the fact that you're an amateur astronomer or follow space science very closely, and. So if you just something about that.
Dr. David Gaba: Well, it is one of my hobbies is, indeed, following both the human and robotic space programs and space sciences. And as I watch a lot of lectures online and physics and astrophysics and things like that, one of the things I noticed as I saw those lectures and read a lot of reports and papers, and they're constantly making reference to what are called the decadal surveys that are done in planetary science, in astrophysics, and in earth science. That means every ten years, approximately, the funding agencies, NASA and the NSF, commission the National Research Council to conduct one of these decadal surveys. They're done, really, by the scientific community with quite a bit of input from the scientific community. They commission white papers for the planetary science decadal survey. They got 199 white papers from all over the country. They do town hall meetings and scientific meetings all over the country, all over the world, and at some other venues. They really try very hard to get broad input from the entire scientific community in that arena. And then there's working panels and a steering committee that builds a comprehensive view of where the field is at and then what the key priorities are. They establish what are the main themes. Within those few themes, what are the key goals and objectives, and then working down from those goals and objectives to the kinds of information that are needed to address those goals and themes and the instruments and missions that would be needed to acquire that information. And in the case of the decadal surveys where they have missions that may costs hundreds of millions or even billions of dollars, the decadal surveys actually prioritize which mission should fly in a given decade. Now, in health care and in simulation, we don't have quite that magnitude, but I think we can use many of the same processes to try to better establish what do we know now. What do we need to know to really move these fields forward and to establish where they fit in the structure of health care and the improvements that we seek in quality and safety, and then what kind of studies, individual studies we would need to commission or to encourage to get the information that we need. And this could be used either in a top-down format to decide really as a professional society and to perhaps influence the funding agencies in a top-down fashion, but I think it can also be used in a bottom-up fashion. If you're an investigator, you have something you think is interesting to study, you can start to place what you want to do in a broader context of the measurements, the objectives, goals, and themes that the community as a whole has laid out. So I'm actually working to lobby various parties to try and have a decadal survey-like process established on an every ten-year basis for the field of simulation in health care.
Dr. Walter Baile: That would be extraordinarily valuable in providing a roadmap for the future research and educational efforts and. I know that everyone is sort of very, very interested in some of the, not only the research questions but some of the practical and implications of simulation, and do you see us getting to the point where that we'll use it in assessing the competency of practitioners to, you know, aside from even, you know, obvious things like performing some of the more technical aspects, to work as part of a team? Do you see where you have that sort of perspective that that will occur sometime in the future?
Dr. David Gaba: I do, although I used to think that some of these things were a decade-long proposition, and now that I'm in my third decade of doing this, I realize it's a decades-long proposition. I think we're still building the scientific basis of establishing metrics for those kinds of assessments and understanding how best to do them. I'm involved in a multi-center trial funded by AHRQ that will graph performance assessment onto an ongoing process of simulations for board-certified anesthesiologists and their maintenance of certification program. So these will be actual experienced clinicians, not trainees, and we will be studying performance assessment techniques of both measuring the medical and technical performance on challenging scenarios, but also their interpersonal teamwork and non-technical skills as well. So creating the scientific basis of understanding the psychometrics of those assessments and the issues of how you create the measurement instruments for those soft skills, if you will, is still in its early days. We've made some progress in the last couple of decades, but we have a ways to go, but I do think in another 10 or 20 years that hopefully, at the most, we would start to assess people in high-stakes fashion for both their medical and technical performance and their skills in these non-technical [inaudible].
Dr. Walter Baile: And speaking of non-technical things that I know that the relationship with the patient and how practitioners relate to them is a very important measure of patient satisfaction and maybe also patient safety, and I notice that what's starting to creep into the literature is some descriptions of assessments of medical students at the time that they come in for interviews, of assessment of actual patient interaction. So they may be put with a standardized patient to see whether or not they have attitudinal and interpersonal skills that would enhance their ability to, actually provide a foundation for their ability to interact with patients. And I was surprised that in some places, like I think McMaster in Canada and some of the Israeli schools, and that's kind of grabbed, people grab a hold of that as a tool for helping sort out who we want to be doctors. And -
Dr. David Gaba: Well, that's true, and actually Stanford is one of the institutions that has adapted what's called the multiple mini-interviewer, MMI, in which instead of having a 45-minute interview with a faculty member, you'll have eight stations lasting about eight minutes each, and each will sort of be a challenge or a task rather than a rambling conversation. The raters for those stations range from faculty members to current students to patients or families, and the tasks are quite various, and many of them are really arranged around, looking at these non-cognitive skills, if you would. It's not asking people what they know, but trying to assess, you know, if you will, what kind of people they are. And also having more of these encounters makes it a fairer assessment than just these one-shot trains of interviews. So that technique is, it's been very successful so far at Stanford, and there's interest not only at other medical schools, but there's interest in other arenas where you're trying to interview people to find out what they're like and whether they're going to be good for your residency program or other things. I think those techniques, which are also simulation, are going to be used, you know, in much larger fashion in the future.
Dr. Walter Baile: Well, thank you very much for chatting with us. It's been very enlightening, and it, although the field is not young, it sounds like it's always on its, the threshold of new discovery and challenges. So hopefully we can have you back in a few years to give us another update.
Dr. David Gaba: Well, it would be my pleasure. Thanks very much.
Dr. Walter Baile: Well, we've been talking today with Dr. David Gaba from Stanford University. Dr. Gaba will be lecturing today as part of our ACE lecture series in achieving communication excellence, giving us an update and a vision of simulation and its future. So be sure to look for it on our website.
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