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Practicing to Practice

Medical simulation breathes life into physician training

The New Physician April 2007
When Joshua Franczyk has to go to work, he often pretends he is sick. It is right there in his job description: “Pretend to be sick.” Gasp for breath; cry out in pain; call for a doctor; cough directly into the microphone.


Some days he suffers from appendicitis; some days it’s acute anemia. As a skilled patient–actor, he’s had assignments become even more exotic lately.


Around the country, trained medical actors like Franczyk verse themselves in the symptoms of leaking aortas. They show signs of developing avian flu. They complain about hot flashes and fainting spells. They feign aching joints, headaches, insomnia and shortness of breath—or maybe even mimic the subtleties of Gorlin syndrome or Kugelberg–Welander disease.


The third-year medical students attending to the “patient” with the raspy voice or the swollen knee are on videotape too, playing out the patient encounter at the University of Pittsburgh’s Peter M. Winter Institute for Simulation, Education and Research (WISER). Cameras whirl to capture the scene—the moments of indecision or screw ups, as well as the triumphs.


Franczyk is a bona fide simulation specialist: one part performer, six parts systems engineer and a former anesthesia technician. He joined the staff of WISER two years ago and has helped its SimMedical Department run 10,000 medical encounters with a variety of simulation techniques, including programmed mannequins. He often works with equipment—high-tech and low—to help professors create real-time scenarios for medical students in as accurate a setting as they can produce.


On the low-tech end, live actors, called “standardized human sim-
ulators” or standardized patients, help pace students through outpatient examinations. Suturing pads are used for practicing with
needle and thread.


On the other end of the tech spectrum, computers in a control room create an array of symptoms in highly sophisticated mannequins. From the control room, like the man behind the curtain in “The Wizard of Oz.” Franczyk will cough, wheeze, or say, “Ouch, that hurts!”


And, of course, in one of the distorted realities of this brave new world of medical education, part of his job entails keeping the mannequins “alive.”


In the forms of “SimMan,” “Stan D. Ardman,” “Noelle,” “SimBaby” and “Harvey,” medical mannequins have shot into the modern age with anatomical and physiological structures brought to life by electro-mechanical innards that push as far as technology and creativity allow. Such simulation began in 1960 with Resuci-Anne, the legend of CPR training, first introduced by Norwegian doll maker Asmund S. Laerdal and modeled after the late 19th century death mask of an unnamed drowning victim, known as “the girl from the River Seine.” Since then, mannequins in medical schools have been ailing on the job with increasing fervor and at a more rapid pace.


The modern medical simulation era began, some say, when Dr. David Gaba, now the associate dean for immersive and simulation-based learning, and professor of anesthesia at Stanford University School of Medicine, read Charles Perrow’s 1984 book about the Three Mile Island nuclear power plant disaster Normal Accidents: Living with High-Risk Technologies,” and thought, he said recently, “This is just like anesthesiology.”


Medical errors, Gaba felt, could be viewed as a case of systems breakdown, rather than individual error. Simulation was an opportunity to practice and perfect a team approach to medical education; one that could put failsafe mechanisms in place, with nurses, technicians and doctors all more aware of what the other was doing. A team, he reasoned, could reduce mistakes in hospitals.


In 1986, he put together what he called “a virtual pseudo-instrument,” which could produce blood pressure data without using real patients. In his second try, Gaba used “mostly off-the-shelf stuff” inside the shell of a mannequin. These efforts evolved into ever more sophisticated medical dummies, and ultimately he licensed the technology to CAE-Link, a division of the company that produced the original Link Trainer for aviation simulation.


The bar on simulation thus raised, mannequins began to proliferate. With the Institute of Medicine’s 2000 report, “To Err Is Human: Building a Safer Health System,” which chronicled medical accidents as one of the leading causes of preventable deaths in the United States (estimated at 44,000 to 98,000 per year), the race to create patients who refuse to die—mannequins, in other words—was on for real.


INTENSITY


At WISER, high-tech dolls, which can run as high as $200,000, are often addressed with the generic endearment, “Mr. Smith.” At Stanford—which has four simulation centers and a new one in the works—mannequins are named after Grateful Dead songs. Gaba is quite pleased that Johnny Goode, August West and the Doo-dah Man will suffer a variety of illnesses at the flip of a switch.


At the University of Michigan Health Systems (UMHS), Clinical Simulation Center director Pamela Andreatta says the mannequins are so real, “there’s a level of intensity that you would see in the same way that you would see in a clinic.”


Students anthropomorphize the mannequins, she says. “People try to comfort them.” She herself confesses that “when I’m doing a tour and the mannequins are out, I go over and stroke their heads.” In fact, one unsubstantiated report claims that a nursing student was so distraught when her mannequin died that she went to grief counseling.


Reality is one way to go. But the push for new training techniques extends beyond whole-body mannequins to “task-trainers” that allow students to practice a specific surgical skill, including laparoscopic procedures. At UMHS, students use “box trainers” that allow them to get the feel of handling endoscopic surgical equipment. Using an endo-stitch tool, for example, students can practice cutting up a sponge or, if they prefer, “removing the skin from a tangerine,” Andreatta says.


Simulation is getting wilder and weirder, too. With more innovators reaching to create training environments that imitate everything but the pain and the dying parts of medicine, the gloves are off. A handful of Cave Automatic Virtual Environment (CAVE) structures around the country now allow medical students to practice in a room with projections on three walls that put them into real-life scenarios. At UMHS, the CAVE has five walls, and participants wear goggles to create a 3-D effect.


Gaba, once happy with a computerized blood pressure cuff, now dreams of a “virtual hospital,” with medical students, nursing students and residents playing the professional parts and mannequins filling in as patients. Literally and virtually, the sky is the limit.


GRAND ILLUSIONS


Behind it all, however, is a central question: Can simulators replace traditional methods of hands-on teaching? “It wasn’t long ago, about 15 years ago, when, as a medical student, you were simply monitored by a more senior physician and, when [he or she] felt you were good enough to go, and you had put in the requisite number of hours, you were on your own,” says Mark Scerbo, co-director of Eastern Virginia Medical School’s National Center for Collaboration in Medical Modeling and Simulations, and professor of psychology at Old Dominion University, where he works with and tests simulators.


That follow-the-doctor-around approach, commonly called “see-one, do-one, teach-one,” is not going away overnight. Nevertheless, Scerbo says, “What the world of training in educational medicine will look like five years from now is going to be so totally different than it was 15 or 20 years ago, [yet] it is hard to believe that they haven’t been doing this all along. They will never go back to the old way again.”


There is a race to create more realistic, more believable simulation techniques—on computer, with live actors, with mannequins. But as the push for realism goes on, Scerbo worries that some of the simpler, more subtle skills might be skimmed over. One phlebotomy simulator that he evaluated missed the mark by asking students to apply a tourniquet by simply clicking the computer’s mouse. “So you never learned how to actually put a tourniquet on at the correct level of tension for a given patient,” he says. “Every simulation system that is out there, from the Cadillac down to the least expensive, is deficient in some degree of physical and functional fidelity,” he claims.


Clearly, success of the illusion is one thing; success of the procedural training is another. Scraping the tissue, carving the bone and tying the knots are certainly the first order of business in an operating room, but the planned procedure is generally not where mistakes are made. By watching a master surgeon, proficiency is enhanced, but when a serious emergency occurs, “the senior people take over and bump the junior people out of the way, which is great for the patient,” Gaba says. “But you aren’t learning how to make decisions. And how are you going to learn that if you never get to practice it?”


Practicing one procedure without losing a patient is a universally applauded idea. Practicing 50 times with the same idealistic results is better still. But practice isn’t just about perfection: “It allows the learning to come to a higher dimension,” says Andreatta.


Like tying shoes or driving a car, once the skills are in place, a person can perform complicated tasks without giving them much thought. In a car, for example, you learn by first concentrating on the ignition, the brakes and how the windshield wipers work, she says. Next you learn how to navigate. After a while, however, you can drive effortlessly, aware of your surroundings, but without much brainpower in play. You can, in time, drive around while writing a term paper in your head.


You can imagine, then, who shows up in CAVE scenarios at UMHS. Distraught family members can be seen screaming in the background when the door to the virtual operating room opens up. Three-dimensional images of technicians come and go. Announcements and sirens blare. The idea is to practice a technique so many times that even in the chaos of real urgency, the technique becomes automated, Andreatta says.


“Any time in a medical situation, there’s a lot to remember. One of the kinds of things we can do is automate as much of that response as we possibly can, so that when the physician or the nurse or the technician is in the field or in an applied environment of any context, it allows them to focus their cognitive resources and their energies toward the specifics of that scenario,” she says.


Administrators are happy to point to another forward leap in medical training that simulation provides: consistency. This breakthrough has had a ripple effect: The Food and Drug Administration now considers simulation training de rigueur for practicing carotid stent procedures, and the American Medical Association cites one study finding that simulation training results in six times fewer errors in laparoscopic cholecytectomies, and another finding 30 percent faster surgeries dissecting the gallbladder from the liver bed.


If that’s not convincing, how about a discount on physicians’ liability insurance? With simulation training among other points on a résumé, CRICO Risk Management Foundation, which insures Harvard medical affiliates, has knocked off 10 percent from obstetricians’ $61,130 annual insurance bill; anesthesiologists with simulation training are allowed a 5 percent discount. Other insurers are following suit.


No dead patients—check. Consistency, teamwork, decision making—check. Practice before you embarrass yourself in front of your patients—check. Funny names for your mannequins—check. The benefits are enormous and the potential perhaps larger than that. Ten years since it seriously took hold, the medical field has yet to spend $100 million on simulation-based training, Scerbo calculates, while the Federal Aviation Agency, he notes, spends $800 million per year on this type of training alone.


The aviation business has a saying: that the pilots are always the first ones to the scene of an accident—a sentiment appreciated by third-year Stanford medical student Dora Casteneda. “I take the training very seriously,” she says. “As a student, I don’t want my first experience with trauma to be a real-life trauma.”


She adds with conviction, “It’s great to practice practicing medicine, and nobody gets hurt.”
Anthony C. Hall is a freelance writer in Dryden, New York. Direct comments about this article to tnp@amsa.org.