The Use of Simulation in Healthcare: An Award-Winning Doctor’s Insights
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“We’re just putting out version four of our emergency manual. We make it available for free under a Creative Commons license. Version three has been downloaded tens of thousands of times, maybe. It’s been translated in a number of different languages, including Mandarin…People all over the world are using it.”
Dr. David M. Gaba, Winner of the 2021 Eisenberg Award for Individual Achievement
Healthcare simulation programs have proliferated to numerous areas of the healthcare system, including hospitals, medical and nursing schools, community college programs, and clinics, both in the United States and internationally. Over time, simulation has gained acceptance in healthcare, as the profession learned to appreciate how simulation has improved safety in other high-risk settings, such as aviation.
According to the Agency for Healthcare Research and Quality, simulation is promising because it offers a range of customizable, easily accessible learning opportunities. In a high-risk and deeply technical field such as healthcare, it is critical to have the opportunity to make “safe mistakes” in clinical care and learn from them without causing harm. Simulations also offer a highly standardized environment where researchers can answer the tough questions that are difficult to study in real-world medical environments.
Now, a pioneer in simulation in healthcare has been honored with the equivalent of a lifetime achievement award. Stanford researcher and the VA Palo Alto Healthcare System’s Dr. David M. Gaba has been named this year’s recipient of the Eisenberg Award for Individual Achievement, the accolade awarded annually by the National Quality Forum and the Joint Commission.
The award recognizes Dr. Gaba’s unique contributions to medicine and healthcare quality through the use of mannequin-based simulation and unique protocols to reduce human error in hospitals.
As the American healthcare system reels from the worst global pandemic in a century, Dr. Gaba reflected on his lifetime of work to make healthcare safer.
The Role of Patient Actors in Healthcare Training Simulations
Specially-trained actors, portraying patients, remain one of the most effective ways to simulate hands-on clinical experiences for physicians in training. “Many of them are real card-carrying actors,” Dr. Gaba said. “They’re specially trained to realistically play lots of different kinds of patients and backgrounds and underlying diseases.”
The simulation starts with the basics: taking a physical history, perhaps doing some parts of the physical examination. For this, Dr. Gaba said, “there’s no better simulator than another human being.”
Actors can also pose as patients’ family members for use in difficult conversations, training medical students on how to deescalate sensitive medical situations. Actors are also trained in how to give feedback to participants.
But limits exist. Obviously, actors don’t like being the subject of invasive procedures: “Needles and tubes have lethal conditions that we may or may not be able to resuscitate them from,” Dr. Gaba said. “That’s where the other modalities of simulation are very important.”
Measuring the Effectiveness of Simulation
These days, you can’t manage what you can’t measure. So naturally, measuring the effectiveness of simulation is a lively area of research. In the 1980s, this led to the first of the more modern era of simulators.
Drawbacks of those early measurements included that it was “retrospective, biased, and [provided] limited information,” Dr. Gaba shared.
Modern-day simulations watch how different people respond to challenging situations. Research along these lines that Dr. Gaba started in the late 1980s continues to the present day. Currently, he is a major co-investigator in a multiyear, multicenter federally-funded study of such simulations. It’s the second big study through the federal Agency for Healthcare Research and Quality that he and his colleagues have done. One of Dr. Gaba’s colleagues at Vanderbilt, Dr. Matt Weinger, is the principal investigator.
“We’re doing very detailed work on the exact kinds of decision-making strategies and behaviors that people utilize,” Dr. Gaba said. “It’s very difficult to make objective measures, but we’re learning.”
The goal remains to expose clinicians to real tough situations, and then get a chance to talk about it during post-training debriefing. “Even in the clinical world, where we encourage debriefings, it’s often difficult to be able to do that,” Dr. Gaba said. “And people have other patients to take care of.”
Simulation and the Problem of Clinician Burnout
In present-day healthcare, burnout has become a critical problem among employees, including doctors. Optimizing simulations often involves tradeoffs so the learning can be most effective and efficient. Dr. Gaba explained that high-fidelity simulations try and replicate the realities of the clinical world, but some modern aspects of the healthcare environment resist easy replication in a simulation.
“One thing we haven’t been easily able to do is to replicate the use of the electronic health record,” Dr. Gaba said. Given that his specialty is anesthesiology, it’s even more complicated, because anesthesiologists monitor readings in real time, such as vital signs—readings that are not normally stored in electronic health records.
“You’re looking at stuff that’s constantly changing and maybe there’s data being collected,” Dr. Gaba said. “It’s a different environment than a clinic where you see a patient [and] you type some stuff into the electronic health record.”
As it turns out, technologies have made some functions in healthcare easier but more difficult in other regards: “They’re not always that well-designed from the human factors standpoint,” Dr. Gaba said. “But I think that a lot of the burnout comes more from the complexities and structures and production pressure of the work rather than from the technology per se, although frustrations with technology don’t make life any easier. That’s for sure.”
Nevertheless, simulations such as the ones Dr. Gaba creates do address some very complex and life-threatening situations. Depending on the decisions made by students, simulated patients might end up in very serious condition or even die.
Dr. Gaba mentioned that detailed debriefings don’t just focus on the medical and technical best practices. Up to 50 percent or more home in on the more nuanced aspects of teamwork and communication. Simulations try to capture how clinicians feel and respond to challenges, including ethical ones. “We really are trying to use that kind of high-fidelity simulation to recreate the complexities of the clinical world,” Gaba said.
Simulation Technology in Action: The Role of Open-Source Emergency Manuals in Anesthesiology
The 2021 Eisenberg Award highlighted three areas where Dr. Gaba made a difference in medical simulation.
The first was the invention of a modern mannequin-based simulator, evolving from simple to more complex over the years.
Secondly, Dr. Gaba and his team adapted the non-technical training that aviation was doing into the healthcare arena.
But the third area makes a difference in emergency rooms around the world every day: “We expect everybody to need to memorize everything and to have it available from their head and their fingertips,” Dr. Gaba said. “And that’s just not realistic. Pilots have been using checklists and emergency manuals of what to do when various things happen. They were almost nonexistent in healthcare.”
So it was critical for Dr. Gaba’s team to distill the simulation-based curriculum and crisis resource management, first into textbooks, and then ultimately into what Dr. Gaba calls business cognitive aids—specifically, an emergency manual, similar to what the pilots have used but optimized for real-time use in healthcare practice.
To that end, Dr. Gaba started the Stanford Anesthesia Cognitive Aid Group at Stanford University to generate various versions of these real-time aids in the years that followed.
Most recently, Dr. Gaba’s team recently released version four of its emergency manual with the assistance of a colleague who is a human factors expert from NASA Ames Research Center. Stanford makes it available for free under a Creative Commons license. Dr. Gaba estimates that version three has been downloaded tens of thousands of times, and has been translated into a number of different languages, including Mandarin.
It’s even led others to develop their own emergency manuals and led to the establishment of the Emergency Manual Implementation Collaborative.
Medical Simulation in the Future: The Growing Role of Artificial Intelligence, Machine Learning & AR/VR
One of medicine’s cutting edges today is artificial intelligence, the notion that machines and algorithms can perform the kind of decision making once reserved for the sort of medical students Dr. Gaba’s simulations and emergency manuals have been training over the years.
“I had been involved earlier in my career in three different AI projects for exactly that sort of decision-support for highly dynamic medical arenas like ours,” Dr. Gaba said.
While AI, by all rights, should be quite valuable, the key thing is to figure out how best to integrate AI with people, and in some cases, with robots, Dr. Gaba said: “You get the best synergy from all of those things.”
When he was just starting out, Dr. Gaba thought the goal of AI would be to make great people (or smart people) even smarter and more capable. “But after seeing some situations, including those with my own extended family, I came to realize the biggest benefit might be in providing better a safety floor for the places or people or circumstances that aren’t so good,” he said.
The number of different roles that AI could play in the next decade or so remains very interesting, Dr. Gaba added. “And in a somewhat similar but completely different vein, I think that’s also going to be true of virtual reality and augmented reality as the modality for simulation,” he said.
“I think we’re on the cusp of a period in which we’re already starting to work with virtual reality, augmented reality, and simulation, but it’s still the early days. Maybe the next five to 10 years are going to see a lot of growth in that as well.”